Nursing Crew Resource
Management:
High Reliability Behaviors for front
Line Nurses
Gary L. Sculli MSN, ATP
Director of Clinical Training Programs
VHA National Center for Patient Safety
Objectives
1.
Compare and contrast cultures – high reliability and
professional nursing
2.
Explain a cultural analysis of VHA nursing as an impetus for a
Crew Resource Management (CRM) initiative
3.
Present a Nursing Crew Resource Management (NCRM)
program overview
4.
Discuss specific CRM based behaviors that nurses can
implement to reduce the level of risk for hospitalized veterans
5.
Outline specific outcomes found on nursing units that have
implemented NCRM within the VHA
Vision
National Center for Patient Safety
Institute of Medicine (IOM)
“…establish team training programs …using
proven methods such as
crew resource
management
training techniques employed in
aviation…”
•
Team training (CRM)
•
Human factor awareness
•
Regulatory protection
•
High degree of standardization (SOP)
•
Briefings
“Culture Shock” –
High Reliability
•
Checklist Discipline
•
CVR / FDR
•
Incentivized non punitive reporting
(anonymity / immunity)
•
Highly formalized – perpetual training
•
Performance checking via simulation
“Culture Shock” –
High Reliability
•
Hierarchical Relationships (Nurse – Physician)
•
Human Factors not emphasized
•
Expectation to complete non nursing functions
•
Varying degrees of standardization
•
Fear and Shame in reporting errors
•
Haphazard recurrent training
•
Absence of performance checking via
simulation
RN
Level 1
RN
Level II
Nursing
Assistant
LPN
VA Patient Safety Culture Survey 2009
Mean Scores
Front- Line Nursing and All VHA
Overall
Perceptions of
Safety
Non- Punitive
Response to
Error
Teamwork within
Hospital Units
Teamwork across
Hospital Units
Mean Scores
RNI, RN II and LPN, Nursing Assistant
•
Shame
•
Teamwork Across Hospital Units
•
Feedback & Communication
about Error
RN I
&
RN II
Lower
Mean Scores
RNI, RN II and LPN, Nursing Assistant
LPN
&
N/A
Lower
•
Communication and Openness
•
Teamwork Within Hospital Units
Tenerife – March 1977
(Fatalities 583)
Originated in a
1979
NASA workshop
•
Reduce error
through better use of human
resources
•
Manage error
by employing specific safety
behaviors
(CRM) Crew Resource Management
NCRM - Program Layout
= Clinical Questionnaire
Logistics
& Pre-work
2 months prior
Training
on site
1 week
Refresher
Training
At 1 year
Project Implementation
Consultation
12 months
Projects
1.
Mitigating Distractions
2.
Checklist development and Implementation
3.
Team Briefings / Debriefings
4.
Situational Awareness Countermeasures
5.
Fatigue Management
Program reception at front line?
16
0 20 40 60 80 100 Program objectives were relevant to my professional
needs/interests I developed new skills/knowledge as a result of my
participation in the program I will be able to use my new skills/knowledge in my regular
work assignment Overall, the program was worthwhile I would recommend this program to a friend or co-worker
Percent of respondents that agreed or strongly agreed
Baseline (N=478) Follow-up (N=207)
NCRM Foundation
Human
Error
Systems
Behaviors
Systems
“Zero error is NOT realistic”
?
Fault Tolerant System
system tolerates errors
but still functions
successfully…
“Zero error is NOT realistic”
The Error Pyramid
“Fault Tolerance”
TRAP
ERROR
AVOID
ERROR
MITIGATE
CONSEQUENCES
of ERROR
Leader Behaviors
Building the Team
Complete Control
Input not welcome
Autocratic
Intimidating
Rude
Hostile
Leadership Style
“Dictator”
ISMP Survey on Workplace Intimidation
(2003, 2005, 2008)75% Nurses and Pharmacists use
“avoidance techniques” ISMP, 2005
1.
Interpersonal skills
2.
Invite and Expect Participation
3.
Use Open Ended Questioning
4.
Set Acknowledgement Expectation
5.
Briefings
6.
Debriefing
Team Building Behaviors
Sender
Receiver
Leadership Grid
(x,y)
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Concern for Task
(x)
Concern
for People
(y)
1,1
Horrible Leader
1,9
Country Club
Style
9,1
Produce or Perish
9,9
High Motivation,
Morale, Teamwork
Assertive Advocacy
Followership
Passive
Independent Critical Thinkers
Followers
Advocacy
Active
Dependent Non-Critical Thinkers
Air Florida Flight 90
January 1982
January 13, 1982
Fatalities 79
15:59:58 - F/O
God, look at that thing. That doesn't
seem right, does it?...Uh, that's not right.
16:00:09 - CA
Yes it is, there's eighty
16:00:10 - F/O
Naw, I don't think that's right…
Ah, maybe it is.
Assertive Advocacy
Avoiding
“Hint and Hope”
Communication
Standardized Tools
3 “W”s
1.
W
hat I see
2.
W
hat I’m concerned about
3.
W
hat I want
“3Ws” Case Study
A procedure is about to begin in the
operating room on a patient having several
laryngeal polyps removed. The surgeon
begins the case. The circulating nurse
notices that there has been no discussion of
procedures for reducing the risk of an intra
airway fire during electrocautery.
4 Step Tool
1. Get Attention -
Use title
or
first name
2. State Concern -
“I’m uncomfortable with”
3. Offer Alternative -
“I want you to…”
4. Pose question -
Get resolution
Assertive Communication
Standardized Communication Tools
Nursing Questionnaire (TW Domain)
0% 20% 40% 60% 80% 100%
***The physicians and nurses here work together as a well-coordinated team. ***It is easy for personnel here to ask questions when there
is something that they do not understand. ***I have the support I need from personnel to care for
patients. ***Disagreements in this clinical area are resolved appropriately (not who's right, but what's best for pt). ***It is difficult to speak up if I perceive a problem with
patient care. ***Nurse input about patient care is well received.
Baseline 6 Months 11 Months
29% Improvement
75% Improvement
Levels of Situational Awareness
Level 1
perception
Level 2
comprehension
Level 3
projection
Make Decisions
Situational Awareness (SA)
Significant Challenge for Nurses
Medication Variance
Fall with Injury
Wrong Patient
Wrong Procedure
Failure to Rescue
NARCAN, D50
ACLS
LOW
(SA)
THREATS
STRESSORS
C
o
g
n
it
ive
R
e
so
u
rce
s
Apply the 1,2,3 Rule
Immediate
Action
1. Step Back
2. Analyze
3. Use Resources
As soon as
POSSIBLE
vs.
PRACTICAL
Knowing / Recognizing Red Flags
•
Failed Cross Check
•
Failure to meet targets
•
Confusion
•
Not following Policy
•
Fixation
•
Failure to Delegate
•
Not communicating
•
Not addressing discrepancies
Team Monitoring & Cross Checking
PM
Pilot Monitoring
Staff Monitoring
(NM)
•
Short
•
Done by Leader
•
Informative
•
Structured
•
Opportunity for Questions
RN Led Briefings
RN to Team Briefing
•
Greet Team
•
Follow Policy
•
Invite participation
•
Acknowledgements
•
Clarify roles
–
RN, LPN, N/A
•
Patient Risks
•
Define Team
•
Questions
Huddle = Briefing
3C
HUDDLE
•
ANY CHANGES SINCE REPORT? IF SO WHAT?
•
ANY DISCHARGES?
•
HOW ARE YOU DOING?
•
DO YOU NEED HELP?
•
CAN YOU HANDLE YOUR ASSIGNMENT?
•
CAN YOU GO TO LUNCH?
•
CAN YOU TAKE AN ADMISSION?
•
WILL YOU BE ABLE TO LEAVE ON TIME?
•
IS THERE ANYTHING ELSE?
*
THIS TAKES ABOUT 10 MINUTES MAX TO WITH ALL NURSES AND NURSING
ASSISTANTS PRESENT.
Unit Acquired Pressure Ulcers (UAPU)
•
UAPU
Rate
FY 10 qtr. 2 =
4
•
UAPU Rate FY 11 qtr. 1 =
0
Blood Glucose Monitoring
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
0601 - 0700
1100 - 1200
1601 - 1700
2001 - 2200
33%
Hypoglycemic Events
71%
Hyperglycemic Events
Blood Glucose Related Events
15
in FY10 Q2 to
10
in FY11 Q1).
Checklists
•
Support the user
•
Puts knowledge in the world
−
“Read and Verify”
−
“Read and Do”
Read and Verify
Before Takeoff
Window Heat………..ON HIGH
Anti-Ice……….ON
Flight Instruments & Radios………..SET
Yaw Damper………....ON & CHECKED
Flight Controls………..……..CHECKED
Stabilizer Trim………..SET
Flaps / Slats………...15 & GREEN
Electrical………...NO LIGHTS
Fuel Pumps………...SET FOR TAKEOFF
Fuel Heat……….OFF
Hydraulics………..PRESS & QTY NORMAL
Elevator & Rudder Lights………...….OFF
Air Cond & Press………...SET FOR TAKEOFF
EPR & Airspeed Bugs………..…SET
Transponder………...ALTITUDE
Take Off Briefing………COMPLETE
Read and Do
Read and Do Checklist
4% - 22%
Calls to Rapid Response Team
25% - 12%
Failure to Rescue Eve
nts
Central Line Mishap
Central Line Removal Checklist
Before Removal
(Read and Verify)
Patient Identification……….Confirmed X 2
Supplies……….….At bedside
Supine Position………..Confirmed
HOB (Slight Trendelenburg or Flat)……….In position
Sutures ………..Removed
Removal
(Read and Do)
Patient………Confirm in supine position
Patient………Take a deep breath and hold
Line Remove ……….Pull parallel to skin in steady motion
Pressure Dressing………Immediately apply
Patient………Exhale
After Removal
(Read and Verify)
Occlusive Dressing………Applied
Patient………...Instructed - Bedrest X 30 minutes
Staff and Patient……….Instructed - Monitor per protocol
Sterile Cockpit Methodologies
Reducing Distractions
•
“Sterile Cockpit Methodologies”
Mean Number of Distractions
0
0.5
1
1.5
2
2.5
1
2
3
4
5
6
7
8
9
10
11
Nursing
Hospital Staff
Visitor
Patient
Other
0
0.5
1
1.5
2
2.5
1
2
3
4
5
6
7
8
9
10
11
Hospital Staff
Patient
Mean Number of Distractions
Medication Error Rate
Pre Intervention
3.95 / 1000 bed days of care
Post Intervention
2.26 / 1000 bed days of care
36%
High Fidelity Simulation
•
Unit Specific Clinical Scenario
Clinical
Simulation
4
5
6
7
8
Pre
Post
Hoeksemer et al., unpublished
Discussion
References
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Fore, A.M., Sculli, G.L., Albee, D., & Neily, J. (2012). Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit based project. Journal of Nursing Management.
Gaffney, F. Seddon, R. & Harding, S.W. (2005). Crew Resource Management: The Flight Plan for Lasting Change in Patient Safety. HCPro.
Helmreich RL, Merritt AC, Wilhelm JA. The Evolution of Crew Resource Management Training in Commercial Aviation. Int J Aviation Psych. 1999; 9(1):19-32.
Nemeth C. Improving Healthcare Team Communication: Building on Lessons from Aviation and Aerospace. Burlington, VT: Ashgate; 2009.
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Sculli G.L., Fore A.M., Neily J., Mills P.D. & Sine D.M. (2011) The case for training Veterans Administration frontline nurses in crew resource management. JONA, 41(12), 524-530.
Sculli G. Nursing Crew Resource Management: Patient Safety for Front-Line Nurses. TiPS. 2009; 9(4): 3. http://www.patientsafety.gov/TIPS/Docs/TIPS_JulAug09.pdf.
Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res. 2006;6:44.
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