Crew resource management training—Clinicians' reactions and attitudes

Home Study Program AUGUST 2005, VOL 82, NO 2

Home Studv Proqram Crew resource ma nagem e n t trai ni ng-

Clinicians‘ reactions and attitudes he article ”Crew resource management training-CIinicians’ reactions and attitudes” is the basis for this AORN Jouvnal independent study. The behavioral objectives and examination for this program were prepared with consultation from Susan Bakewell, RN, MS, BC, education program T professional, Center for Perioperative Education.

Participants receive feedback on incorrect answers. Each applicant who suc- cessfully completes this study will receive a certificate of completion. The deadline for submitting this study is Aug 31,2008.

Complete the examination answer sheet and learner evaluation found on pages 227-228 and mail with appropriate fee to

AORN Customer Service c/o Home Study Program

2170 S Parker Rd, Suite 300 Denver, CO 80231-5711

or fax the information with a @edit card number to (303) 750-3212.

You also may access this Home Study via AORN Online at http://www.aorn.org/j~urnal/homes tudy/default. h tm.

BEHAVIORAL OBJECTIVES After reading and studying the article on clinicians’ reactions to and attitudes

about crew resource management (CRM) training, nurses will be able to

1. defineCRM,

2. discuss the six key components of CRM training,

3. discuss outcomes of reaction and attitude surveys from one group of clinicians who underwent CRM trainihg, and

4. describe the need for additional research about the effects of CRM training on the health care industry.

MANAGEMENT

This progrom meets criteria for CNOR and CRNFA recertiyca- tion, as well as other continuing education requirements.

A minimum score of 70% on the multiple- choice examination is necessary to earn 2.8 con- tact hours for this independent study.

Purpose/Gaal: To educate perioperative nurses about crew resource maoagemen t (CRM) training and the outcomes of reamon and om‘tude surveys conduct- ed with one group of clinicians that undenven t CRM training.

AORN JOURNAL 2 13

AUGUST 2005, VOL 82, NO 2 France - Stiles - Gaffney - Seddon - Grogan - Nixon - Speroff

Home Study Program Crew resource management training-

Clinicians‘ reactions and attitudes Daniel J. France; Renee Stiles;

F. Andrew Gaffney, MD; Margaret R. Seddon, MD; Eric L. Grogan, MD;

William R. Nixon, Jr; Theodore Speroff

n partnership with a commercial vendor of crew resource manage- I ment (CRM) aviation-based safety

training, Vanderbilt University Medical Center (WMC), a level one trauma center in Nashville, is adapting CRM to the health care domain. The medical center has committed substantial human and financial resources to system-wide implementation of CRM in both its adult and children’s hospitals, and the organizational impact and value of this endeavor will be assessed via a focused evaluation.

The Federal Aviation Administration defmes CRM as

the utilization of all available human, informafionnl, and equipment resources fozoard the eflecfive perform

ABSTRACT MANY HEALTH CARE ORGANIZATIONS

are adopting crew resource management (CRM) training from the aviation industry as a patient safety practice.

ALTHOUGH CRM has high face validity, its effects have not been thoroughly evaluated in aviation or health care. Its potential to improve team communicatian, coordination, and patient safety, however, makes efforts to study CRM necessary and worthwhile.

THIS ARTICLE EVALUATES clinicians’ attitudes about and reactions to CRM after they par ticipated in an eight-hour, commercially developed training program. AORN J 82 (August 2005) 214-224.

ance of a safe and eficientfiight. C M is an active process by crewmembers to identih signifi’cant threats LO an operation, communicate them to a per- son in charge, and to develop, communicate, and c a r y out a plan to avoid or mifigafe each threat.’ (p2)

Adapting CRM to the health care domain is an appealing idea because doing so fulfills the Institute of Medicine’s (IOMs) charge to apply knowledge and safety practices from other industries to reduce patient care errors? The aviation industry also could benefit from rigorous evaluation of how CRM training affects organizational outcomes in other industries because CRM‘s cost-effectiveness still is ques- tioned in aviation.3 This article provides an overview of the CRM training course, presents survey data on clinicians‘ and hospital administrators’ reactions to and attitudes about a first expo- sure to CRM, and discusses the next steps for evaluating the use of CRM in health care.

A HIGH PRIORITY RESEARCH AREA The CRM concept was developed in

1979 in response to a National Aero- nautics and Space Administration (NASA) workshop that examined the contribution of human error and failed team processes to aviation mishaps and disaster^.^,^ Federal reports pub- lished subsequent to the NASA workshop estimated that between 50% and 80% of all aviation incidents and acci- dents can be attributed directly to human error involving poor group decision-making, inefficient communication, inadequate leadership, and poor task or resource

Crew resource management has

2 14 AORN JOURNAL

France - Stiles - Gaffney - Seddon - Grogan - Nixon - Speroff

AUGUST 2005, VOL 82, NO 2

been used in aviation for more than two decades. The CRM concept has under- gone five major phases of evolution since its inception, from a model that targeted individual styles and correct- ing deficiencies in human behavior to the current error management model: The basis of the error management model is that human error is inevitable, but errors can provide a great deal of information for safety improvement. Under this model, CRM is envisioned as a set of error countermeasures with three lines of defenses: 0 error avoidance, 0 early detection of error, and 0 minimization of consequences result-

ing from errors.8 One of the specific recommendations

put forth by the 1999 IOM report, To Err Is Human: Building a Safer Health System, was that patient safety could be enhanced if concepts from the aviation industry, such as team training and CRM, were incorporated in health care practices? The IOM re-emphasized this recommendation in its 2001 follow-up report, Crossing fhe Quality Chd~rn .~ The Agency for Healthcare Research and Quality (AHRQ) provided additional support for this recommendation in its evidence report and technology assessment, Making Health Care Safer: A Critical Analysis of Pafienf Safety practice^;^ however, AHRQ ranked the quality of evidence regarding CRM's effectiveness at improving patient safety outcomes as low, primarily because of CRM's limited application in medicine and the near absence of outcomes studies in aviation?

These concerns notwithstanding, the combination of CRM's strong face validity (ie, it appears, on the surface, to make sense); its acceptance in the aviation industry; and the growing recogni- tion that medical errors frequently are caused by failures in team communication prompted AHRQ to designate CRM as a high-priority research area.5

In making this designation, AHRQ noted that the relatively high cost of CRM training influenced this prioritiza- tion because potential purchasers of CRM training need dormation about CRM's cost-effectiveness as a patient safety practice?

CRM TRAINING Crew resource management training

began at VUMC in August 2003 and involves close coordination with and oversight from a medical advisory board. The initial focus of VUMC's CRM implementation has been, and continues to be, the perioperative setting. Full deployment of CRM training and implementation will require several years and will progress simultaneously in several clinical units. In the OR, CRM deployment is proceeding across multiple surgical service lines (eg, general surgery, orthope- dics, neurosurgery, urolo- gy, vascular, thoracic).

The process begins with clinical teams con- sisting of physicians, nurses, technologists, administrators, and other support staff members attending an intensive, one-day CRM training course that targets behavioral skills that enhance teamwork. The vendor representatives who provide the training include former military and cur-

The crew resource

management concept has

evolved from a model that

targeted deficiencies in

human behavior to the

current error management

model.

rent commercial airline pilots whose col- lective expertise spans CRM development and training, human factors engineering, and physiology.

Vendor staff members train surgical teams using two methods: lectures on

AORN JOURNAL 2 15


CRM concepts and principles and case studies that involve role-playing in simulated crisis scenarios. The examples and role playing scenarios used in the class do not use clinical settings as a backdrop, but they stress the importance of leaderslup and communication. For example, one scenario involves the emergency landing of an airplane in a small town because of

Classroom- based training is

followed by focused team collaboration with vendor

represen f a fives to integrate

crew resource management

tools into each clinical setting.

an urgent medical emergency on board. The scenario is designed to test how the passengers manage the care of the sick pas- senger during the flight, communicate the need for help to the pilots, and communicate with para- medics on the ground.

The classroom-based training is followed by focused team collaboration with vendor representatives to develop or customize and integrate CRM tools and practices into each clinical setting (eg, OR, trauma, emergency department, cathe- terization laboratory). Then, simulated clinical scenarios (ie, mock sur- geries, adverse events) are used to demonstrate how CRM processes can be integrated into the clinical workflow in these

domains. Training emphasizes six key areas: 0 managing fatigue, 0 creating and managing a team, 0 recogruzing adverse situations, 0 cross-checking and communicating, 0 developing and applying shared men-

tal models for decision-making, and 0 giving and receiving performance

feedback. MANAGING FATIGUE. The segment on

managing fatigue teaches participants

about signs, symptoms, and causes of fatigue; reviews the physiology of sleep and circadian rhythms; and explains how disruption of these rhythms con- tributes to degraded performance. Participants are taught to recognize fatigue in other team members, and the segment concludes by presenting strategies for obtaining quality sleep and combating fatigue. Factors that can affect sleep include diet and exercise, sleep schedules, and sleep environment. The trainers recommend that individuals stop consuming alcohol and caffeine four to six hours before bedtime, end exercise four hours before bedtime, refrain from reading or watch- ing television in bed, and go to bed and wake up at the same times each day.

CREATING AND MANAGING A TEAM. The module on creating and managing a team reviews benefits of effective teamwork, enumerates the responsibilities of individual members to the team as a whole, and outlines specific team building and management tactics. Instructors em- phasize the importance of 0 using interpersonal skills (eg, intro-

ducing oneself, maintaining eye con- tact, noticing nonverbal cues);

0 conducting briefings before team activities;

0 eliciting commitment and participa- tion from all team members;

0 using open-ended communication; and

0 explicitly acknowledging that mfor- mation conveyed by a team member has been received (ie, closing the

RECOGNIZING ADVERSE SITUATIONS. Recogni- zing adverse situations orients trainees to the human factors engineering concept of situational awareness. The session also specifies cues or red flags (eg, conflicting input, preoccupation, lack of communication, confusion, violations of policies or procedures, failure to meet targets or address discrepancies, fatigue,

loop).

2 16 AORN JOURNAL



Participants learn to articulate assertive statements effectively and in a manner that commands attention, expresses concern,

states the problem, and proposes a solution.

stress) that indicate that an undesirable event is imminent.

CROSS-CHECKING AND COMMUNICATING. The session on cross-checking and communicating teaches new team processes, describes their mechanics, and specifies the elements of assertive statements. After learning the four components of a cross-check (ie, monitor the situation, recognize the red flag, communicate the red flag precisely, and follow-up with feedback), trainees practice techniques for communicating red flags by 0 relaying information to the team or a

0 adding the word check to the input, 0 making an assertive statement, and 0 following up to close the loop. For example, if a team member announces to the team that the patient’s right foot is to be amputated but the team is preparing the left foot for surgery, the team member should state that a discrepancy exists. If the team member receives no acknowledgement that this information was heard, he or she should repeat the statement and add, ”I need a check on the patient’s surgical site.” If there is no response to the check statement, the team member should make an assertive statement, such as

team member,

Dr Jones, I am concerned that we are preparing the wrong sitefor surgery. I think the site may have been marked incorrectly. Lef’s check the operafive consent before proceeding.

The team member should then check the consent with the physician to follow up. Integral to this exercise is teaching participants to articulate assertive statements effectively in a manner that commands attention, expresses concern, states the problem, and proposes a solution.

ELS FOR DECISION-MAKING. The decision-making segment teaches participants to clas- sify team decisions by balancing critical-

DEVELOPING AND APPLYING SHARED MENTAL MOD-

ity (ie, severity, importance) against time urgency. Team members accomplish this assessment by asking themselves a series of questions when problems arise. 0 What is happening? 0 What will I do? 0 How will I do it? 0 Who does what? The process simultaneously provides trainees with a standardized method for analyzing unexpected circumstances and illustrates the value of shared models in team decision-making.

GIVING AND RECEIVING PERFORMANCE FEEDBACK. Finally, the performance feedback segment defines components of postevent debriefings. Feedback debriefings are important because they provide an opportunity to resolve conflicts, prevent recurrences of problems in the future, and facilitate team learning. Crew resource management instructors teach trainees that the team leader should conduct the debriefings and that information exchange should proceed from the least experienced to most experienced team member, with ail members con- tributing. Conversations occur via a structured format in which each individual describes 0 what happened, 0 his or her thoughts about what took

0 what he or she would do differently place, and

if a similar situation arose.

RECIPROCAL BENEFITS The goals of CRM training are to

present individuals with explicit behavioral strategies and then provide oppor- tunities, through role-playing and case scenarios, to practice and hone these skills. Through this process, participants recognize how applying the skills they learn improves individual and team performance. Embedded in the training is a program evaluation component that assesses participants’ knowledge, attitudes, and skill acquisition.

AORN JOURNAL 2 17


Vanderbilt University Medical Cen- ter’s partnershp with its CRM vendor enables customization of the core cur- riculum to the local environment and also allows vendor personnel to observe, coach, and provide feedback to team members outside the classroom in the work environment. Vendor personnel help team members from each work area embed aviation safety tools into their daily processes. This student-teacher interaction has reciprocal benefits; in addition to reinforcing and integrating lessons taught in the classroom, the work

sessions provide a basis for assessing program - The work sessions effectiveness and’e&ance the vendor’s understanding of the dynamic needs of the health care system.

enhance the

CRM EVALUATION vendor3

Clinical teams repre- senting trauma services, the emergency department, and the OR were the first to undergo CRM training at VUMC. Per- sonnel from these areas attended a single, day- long course at a VUMC training facility located apart from the greater medical center. The initial

training sessions began on Aug 27,2003, and concluded on Sept 4,2003. Five sessions were held with an average of 36 members per session. There were 182 class participants, including physicians (13%); nurses (75%); and others, such as technologists and administrators (12%). Participants’ reactions to the training were measured using the vendor’s end-of-course critique, and attitudes were assessed using the CRM human factors attitude survey. The critique and survey are designed to preserve participants’ anonymity, so limited demographic data were collected at

understanding of the dynamic

needs of the health care

system.

the time of administration. The end-of-course critique is a 14-

question instrument designed to assess the perceived need for training, the usefulness of CRM skill sets, and areas for future training. Participants were surveyed immediately upon completion of the day-long training session. Re- sponses to the first 11 questions were measured using a five-point Likert-type scale. Questions one to three used the response scale 0 1 = strongly disagree, 0 2 = disagree, 0 3 =neutral, 0 4 = agree, and 0 5 = strongly agree.

Questions four through 10 used 1 = waste of time and 5 = extremely useful as endpoints, and question 11 used 1 = no change and 5 = dramatic change as endpoints. Frequency analysis and descriptive statistics were calculated for responses to questions one through 11, and a qualitative content analysis was performed on responses to questions 12 to 14 (Table l ) . l o

The CRM human factors attitude survey, a 23-item pretraining and posttraining survey, measures attitudinal shifts regarding CRM behaviors emphasized in individual training modules and has good internal reliability (ie, Cronbachs alpha = .89) in previous uses. The vendor created the human factors attitude survey by modifying aviation-based attitude surveys that were developed previously with the University of Texas at Austin, Tex, and NASA.”,” The survey was administered to participants on the day of their training, immediately before and on completion of the educational program. Responses were measured using a five- point Likert-type scale, in which 0 1 = disagree strongly, 0 2 = disagree slightly, 0 3 = neutral, 0 4 = agree slightly, and 0 5 = agree strongly (Table 2).

218 AORN IOURNAL



TABLE 1 Results of the Crew Resource Management End-of-Course Critique

Question 1. I had a need for this training/information.

2. The training provided me with knowledge and/or skills.

3. This training has the potential to increase patient safety and quality care.

4. How useful will this training be to reduce errors in your practice?

5. How useful was "managing fatigue?"

6. How useful was "creating a team?"

7. How useful was "recognizing adverse situations?"

8. How useful was "cross-checking and communicating?"

9. How useful was "making decisions?"

10. How useful was "performance feedback?"

11. How much will this training change the way you do things?

Mean score Number of (minimum = 1, Standard responses maximum = 5) deviation (n = 177)

4.25 0.69 175

4.33 0.66 172

4.57 0.61 175

4.26 0.71 166

4.16 0.91 175

4.36 0.70 175

4.44 0.67 1 76

4.46 0.69 174

4.33 0.78 1 72

4.35 0.77 158

3.95 0.72 171

12. What changes would you like to see made in this course?

13. What topics would you like to see addressed in subsequent training?

14. Additional comments

Reprinted with permission from Lifewings Partners, LLC, Memphis.

Pretraining and posttraining survey response scores were assessed using paired t tests; a Cronbachs alpha of 0.05 level of significance was used for all sta- tistical analyses.

REACTIONS AND A ~ T U D E S Of the 182 participants trained

between Aug 27,2003, and Sept 4,2003, 177 (97%) completed the end-of-class critique. Response rates for the 11 Likert- type scale questions ranged from 87% to 97%. Respondents' attitudes regarding the utility of the course and its specific subcomponents were positive; question

three, which polled attitudes on the potential for CRM training to improve safety and quality in health care, received the lughest mean score (ie, 4.57). Other attitudes expressed by respondents included agreement or strong agreement that the training 0 had the potqntial to increase patient

0 provided knowledge and/or skills

0 yielded traininglinformation that

In addition, 87% of respondents indicated that CRM training would be very or

safety and quality of care (96%),

(%YO), and

respondents needed (88%).

AORN JOURNAL 2 19


TABLE 2 Human Factors Attitude Survey

1. Team leader and team members can improve decision-making skills through training.

2. Team leader should encourage team members’ questions during normal operations and emergencies.

3. My performance is not adversely affected by working with an inexperienced or less capable team member.

4. Team members should question the decisions or actions of the team leader during a procedure.

5 . Before the procedure, it is important for all team members to be familiar with the tasks and responsibilities of the other members of the team.

6. My ability to detect adverse situations has a direct relationship to the quality of decisions I make.

7. It is necessary for the team leader to explicitly tell team members that he or she wants their input.

8. In response to unplanned events, the surgeon/physician should verbalize plans and ensure that the information is understood and acknowledged by all team members.

9. Good communication and coordination are as important as technical proficiency for the safety of surgical procedures.

10. With trained and experienced staff members, good decisions are almost automatic in the planning and executing of operational requirements.

11. A debriefing and critique of procedures and decisions after each event is an important part of developing and maintaining effective team coordination.

12. A discussion of alternative methods does not make the team leader appear indecisive.

13. As a unit, our debriefing skills could use some improvement.

14. After a team leader has made a decision and announced it to the team, he or she should listen to the reservations of team members.*

15. The staff members in this department need to be trained to “speak up” when they see something that is not right.

16. Supervisors should be able to provide specific instruction and feedback on teamwork skill attainment.*

17. When making decisions, I gather as much information as time allows before making/executing my decision.

18. It is just as important to note and debrief what was done well as it is to note and debrief what needs improvement.*

19. There are circumstances in which another team member should assume control of the event.

20. Recognizing adverse events is one of the most important keys to overall patient safety.

21. If I perceive a problem with the event, I will speak up, regardless of who might be affected.

22. The team formation and decision-making skills of team leaders are as important as their technical skills.

23. During any procedure or shift and in response to unplanned or unbriefed contingencies, the team leader should verbalize plans for procedures and ensure that the information is understood and acknowledged by all team members.

* Indicates items for which diyerences in pretest and postfest responses were not statistically signFcant.

Reprinted zuitli permission fronr LifeWings Partners, LLC, Memphis.

220 AORN JOURNAL



extremely useful in helping them reduce errors in practice.

Respondents also expressed attitudes regarding the usefulness of the individual skills presented in each module. Following the sequence in which the modules were taught, the percent- age of respondents who rated the content as very or extremely useful was

78% for managing fatigue, 90% for creating and managing a team, 91% for recognizing adverse situa-

90% for cross-checking and commu-

86% for decision-making, and 89% for performance feedback.

The greatest variation in respondent attitudes occurred in question 11 (ie, How much will this training change the way you do things?), where options ranged from dramatic change (ie, 5) to no change (ie, 1) and averaged 3.95. This variability notwithstanding, more than 88% of respondents reported antic- ipating significant or dramatic change.

The qualitative content analysis performed on data from questions 12 to 14 provided additional insight into respondent attitudes. When asked whether they would like to see changes made to the course, respondents expressed satisfaction with course content, although some wanted expanded role-playing involving "actual events or situations.'' Opinions on the utility and role of the managing fatigue module were diverse, and the level of emphasis placed on that topic was the apparent source of much dissonance. Sentiments ranged from the statement that managing fatigue has little to do with teamwork to the belief that the topic should be a cornerstone of the course. When asked what topics they would like to see addressed in subsequent training, respondents identified conflict rnanage- ment, more information on managing fatigue, greater emphasis on debriefing

tions,

nicating,

team exercises, and clear suggestions regarding how to integrate the CRM training into WMC's culture. In the section requesting additional comments, responses focused exclusively on appreciation for the course.

Paired t tests performed on the pretraining and posttraining human factors attitude survey responses revealed statistically significant attitude shifts in 20 of the 23 attitudinal markers. Overall, the training appeared to have a positive effect on respondents' attitudes toward the roles of leadership, coordination, and communication in creating and maintaining effective teams. After the training, respondents also indicated positive attitudes toward new skills acquired via the CRM training, such as recognizing red flags and conducting systematic preproce- dure briefings and post- procedure debriefing.

CRM's CONTRIBUTION Despite advances in

evaluation methods and tools, uncertainty persists regarding CRM's contribution to improving aviation and patient safety practices and outcomes. Scientific evaluations suf- ficiently rigorous to auth- enticate the link between CRM practices and aviation safety, whde encour- aging, have thus far been

The training appeared to

have a positive effect on

respondents' attitudes toward

the roles of coordination,

communication, and leadership in creating and

maintaining effective teams.

" W

limited in both number and scope. Using a four-level typology for training evaluation (ie, assessing reactions, learning, behavior, and effect on organizational effectiveness or mission success) one group of researchers critiqued 58 publications that evaluated CRM. They

AORN JOURNAL 22 1


reported that although many research projects collected data on reactions (ie, 46%), participant learning (ie, 58%), and behavioral issues (ie, 55%), very few (ie, 10%) collected data needed to assess organizational impact.’,” In addition, although 24 (41%) of the studies contained information drawn from two or three of the levels, the researchers identified only one (1.7%) that evaluated training data drawn from all four levels. Although participants may consider CRM training important and valuable and associate the experience with subsequent improvements in knowledge and

A substantial in vestment in crew resource

management by the health care

industry must be accompanied by

correlated, measurable

improvements in patient safety.

lukewarm

attitudes, much stronger evidence is required to establish CRM’s organizational effect.

The preliminary data presented in this article are consistent with data previously reported in the aviation and human factors engineering literature.” Clinicians and health care administrators surveyed at VUMC reacted positively to their initial experiences with CRM training by acknowledging the need for team training, reiter- ating the value of related skills sets, and express- ing high levels of agreement that CRM could improve patient safety. Perhaps the most telling result, however, was the

response to the end-of- course critique item regarding respondents’ expectations of CRM’s likely effect on day-to-day practices (1 = no change, 5 = dramatic change, mean score = 3.95 [ie, the lowest-scored question on the critique]). Although respondents acknowledged the training program as important and valuable, some expressed skepticism that the program would exert a lasting effect on work practices.

This skepticism underscores that CRM is not a ”single-dose” safety intervention. Individuals and team members must receive continual training, coach-

ing, and feedback to attain proficiency in the CRM skill set. Crew resource management behaviors must become integral to team identities and organizational work cultures, and this has major implications for the evaluation of CRM in the health care sector and beyond. Administrators and researchers must not permit positive reactions or attitudes regarding CRM training to lull them into a false sense of confidence regarding the intervention’s effect on outcomes. The gap in the research literature concerning CRM’s effectiveness will remain unfilled until CRM’s advocates can document how positive reactions and attitudes give rise to new knowledge and behaviors, sustained transfor- mation of organizational culture, and ultimately, measurable, quantifiable improvements in safety o~ tcomes .~ .~~

MEASURING EFFECTIVENESS Vanderbilt University Medical Cen-

ter is only one of a rapidly growing con- tingent of health care organizations investing heavily in CRM training as a viable patient safety practice.s Imple- menting and maintaining CRM could easily consume hundreds of millions of dollars annually from the health care sector, and such a substantial invest- ment must be accompanied by correlated, measurable reductions in patient errors and improvements in patient safety. Members of the VUMC CRM implementation team in perioperative services and the department of anesthesiology currently are using observation- al methods in the OR to evaluate behavioral change (ie, compliance with CRM safety processes) resulting from CRM training. After the implementation team is able to show that clinicians have adopted and integrated CRM behaviors into their daily work processes, it will study the effect of CRM on various safety metrics (eg, infection, errors).

Health care is well-positioned to ful- fill the need for measuring CRM, both internally and in a manner that can be generalized to other industries. Health care research and quality improvement tools are ideal for conducting multilevel evaluations of CRM’s effect on attitudes, learning, behavior, and safety outcomes.

222 AORN YOURNAL


The tools and methods needed to evaluate how CRM affects patient safety outcomes are plentiful and readily available. The more difficult task facing the health care sector is mustering the determination and fortitude and com- mitting the resources and time necessary to study, diagnose, and rehabilitate the industry using measurement and data collection instruments it has crest- ed and refined to examine whether CRM improves patient safety in health care settings. 03

Daniel J. France, MPH, PhD, is a research assistant professor of medicine and anesthesiology, Vanderbilt University Medical Center, Nashville.

Renee Stiles, PhD, is an assistant professor of medicine, Vanderbilt Univer- sity Medical Center, Nashville.

F. Andrew Gaffney, MD, is associate dean for clinical affairs and a professor of medicine, Vanderbilt University Medical Center, Nashville.

Margaret R. Seddon, MD, is assistant chief medical officer, Vanderbilt Medical Group, Nashville, and a con- sultant for Lifewings Partners, LLC, Memphis.

Eric L. Grogan, MD, is a VA Quality Scholar and surgical resident, Vanderbilt University Medical Center, Nashville.

William R. Nixon, Jr. was the senior research analyst at Crew Training International, Memphis, at the time this article was written.

Theodore Speroff, PhD, is a research associate professor of medicine, Vanderbilt University Medical Center, Nashville.

Editor's note: Publication of this article in no way implies AORN endorsement of a specific training program.

NOTES 1. Crew Resource Management Trainin

Transportation, Federal Aviation Administration, 1993). 2. Institute of Medicine, To Err i s Human: Building A Safer Health System (Washing- ton, DC: National Academy Press, 1999). 3. D L Kirkpatrick, "Evaluation of training," in Training and Development Handbook: A Guide to Human Resources Development, ed R L Craig (New York: McGraw-Hill, 1976) 18.1-18.27. 4. G E Cooper, M D White, J K Lauber, Resource Management on the Flightdeck: Proceedings of a NASAlIndustry Workshop (Moffett Field, Calif: NASA-Ames Research Center, 1980). 5. K G Shojania et al, "Making health care safer: A critical analysis of atient safety practices," Evidence Report&hizology Assessment (Summary) 43 no i-x (2001) 1-668. 6. C Freeman, D A Simmons, "Taxonomy of crew resource management: Informa- tion processing domain," in Pr*oceedings of tke 6th Annual International Symposium on Aviation Psychology, ed R S Jensen (Columbus, Ohio: Ohio State University,

7. Human Factors: FAA's Guide and Oversight of Pilot Crew Resource Manage- ment Training Can Be Improved: Report to Congressional Requesters (Washington, DC: US General Accounting Office, 1997). 8. R L Helmreich, A C Merritt, J A Wilhelm, "The evolution of crew resource management training in commercial aviation," IntevnationaI Jouvnal of Aviation Psychology 9 no 1 (1999) 19-32. 9. Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century (Washington, DC: National Academy Press, 2001). 10. J Corbin, A Straws, "Grounded theory research: Procedures, canons, and evalua-

(Washington, DC: US Department o P

1991) 391-397.

tive criteria," Qualitative Sociology 13 no 1 (1990) 3-21. 11. R'L Helmreich et al, "Preliminary results from the evaluation of cockpit resource management training: Perform- ance ratings of-flightcrews," Aviation, Space, and Environmental Medicine 61 (June 1990) 576-579. 12. R L Helmreich et al, Reirforcing and Evaluating Crew Resource Management: Evaluator/LOS Instructor Reference Manual (Austin, Tex: NASA-University of Texas at Austin, 1990). 13. E Salas et al, "Team training in the skies: Does crew resource management (CRM) training work?" Hurnaiz Factors 43 (Winter 2001) 641-674.

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Crew resource management training—Clinicians' reactions and attitudes