Definition, Measurement, Precursors, and Outcomes of Trust Within Health Care Teams: A Scoping Review.

PURPOSE: This scoping review aims to map the breadth of the literature examining how trust is defined in health care teams, describe what measurements of trust are used, and investigate the precursors and outcomes of trust. METHOD: Five electronic databases (Ovid MEDLINE, CINAHL, PsycInfo, Embase, and ASSIA [Applied Social Sciences Index and Abstracts]) were searched alongside sources of gray literature in February 2021. To be included, studies needed to discuss a health care team directly involved in managing patient care and one aspect of trust as a relational concept. A content count of the definitions of trust and tools used to measure trust and a deductive thematic analysis of the precursors and outcomes of trust in health care teams were conducted. RESULTS: Ultimately, 157 studies were included after full-text review. Trust was the main focus of 18 (11%) studies and was not routinely defined (38, 24%). Ability appeared to be key to the definition. Trust was measured in 34 (22%) studies, often using a bespoke measure (8/34, 24%). The precursors of trust within health care teams occur at the individual, team, and organizational levels. The outcomes of trust occur at the individual, team, and patient levels. Communication was a broad overarching theme that was present at all levels, both as a precursor and outcome of trust. Respect, as a precursor, influenced trust at the individual, team, and organizational levels, while trust influenced learning, an outcome, across the patient, individual, and team levels. CONCLUSIONS: Trust is a complex, multilevel construct. This scoping review has highlighted gaps in the literature, including exploration of the swift trust model, which may be applicable to health care teams. Furthermore, knowledge from this review may be integrated into future training and health care practices to optimize team processes and teamworking.

Twelve tips for using tactical decision games to teach non-technical skills.

Tactical decision games (TDGs) have been used in healthcare and other safety-critical industries to develop non-technical skills training (NTS). TDGs have been shown to be a realistic, feasible, and useful way of teaching NTS such as decision making, task prioritisation, situational awareness, and team working. Our 12-tips for using TDG to teach NTS are based on our experience of integrating them into an undergraduate medical and nursing programme. We cover how to design successful TDGs, how to facilitate and debrief them and how to integrate TDGs into curricula. We have found TDGs to be a cost-effective, low fidelity, and useful method of delivering NTS teaching, ideally as an adjunct to immersive simulation. Learners find them a useful way to be introduced to NTS in a safe and relaxed environment, with particular emphasis on critical decision making and prioritisation.

Well-being workshop: simple acts of care.

BACKGROUND: Well-being encompasses a constellation of multiple interdependent factors influenced by our personal and professional lives. It has a reciprocal relationship with burnout, a phenomenon detrimental to physicians, students and patients alike. Despite this, well-being is not a topic routinely integrated into undergraduate medical and nursing curricula. Local demand and increased global attention provided an impetus to create and deliver an 'Introduction to well-being' workshop. Our aim was to start the well-being conversation early in the professional journeys of students, and to provide strategies to gain and maintain well-being throughout their careers. METHODS: We developed a practical, interprofessional well-being workshop for first-year medical and nursing students. Over six afternoons, 251 students in groups of 12-15 rotated through our three session, interactive workshop focusing on the interrelated subjects of self care, empathy and communication. On completion of the workshop, written evaluation and take-home messages were collected and thematically analysed. RESULTS: The interprofessional aspect of the workshop and the practical tools imparted were positively evaluated. Take-home messages highlighted the need to integrate well-being into the curricula, particularly the self-care aspect. Students concluded that 'simple acts of care' to self and to others were essential for the maintenance and improvement of well-being. CONCLUSION: Interprofessional early year well-being workshops, designed to promote open discussion around the significance of self care, empathy and communication, and to provide practical advice for well-being, were felt to be beneficial by first-year nursing and medical students. Recognising the importance of simple acts of care is likely to advantage not only individuals but also the culture that they shape. Local demand and increased global attention provided impetus to create and deliver an 'Introduction to well-being' workshop.

Exploring the feasibility and acceptability of using tactical decision games to develop final year medical students' non-technical skills.

INTRODUCTION: Clinical decision-making, situation awareness, task management, and teamwork are key non-technical skills (NTS) required by junior doctors. Tactical decision games (TDGs) are low-fidelity classroom-based activities designed to develop proficiency in NTS. This study aimed to explore the feasibility and acceptability of using TDGs as a novel teaching method for final year medical students. METHODS: Final year medical students at the University of Edinburgh participated in a single TDG session. Focus groups were then used to explore students' perceptions of participating in the TDG session and transcribed data from the focus groups was thematically analyzed. RESULTS: Six key themes emerged from the data: "the value of non-medical games"; "giving and receiving feedback"; "observing and reflecting"; "recognizing and understanding NTS"; "dealing with uncertainty and ambiguity", and "introducing TDGs into the curriculum". CONCLUSIONS: TDGs are an easy-to-use, low-fidelity method of teaching medical students about the importance of NTS. Medical students view TDGs as a valuable learning activity that appears to increase awareness and understanding of the importance of NTS.

Exploring patterns of error in acute care using framework analysis.

BACKGROUND: Junior doctors are often the first responders to deteriorating patients in hospital. In the high-stakes and time-pressured context of acute care, the propensity for error is high. This study aimed to identify the main subject areas in which junior doctors' acute care errors occur, and cross-reference the errors with Reason's Generic Error Modelling System (GEMS). GEMS categorises errors according to the underlying cognitive processes, and thus provides insight into the causative factors. The overall aim of this study was to identify patterns in junior doctors' acute care errors in order to enhance understanding and guide the development of educational strategies. METHODS: This observational study utilised simulated acute care scenarios involving junior doctors dealing with a range of emergencies. Scenarios and the subsequent debriefs were video-recorded. Framework analysis was used to categorise the errors according to eight inductively-developed key subject areas. Subsequently, a multi-dimensional analysis was performed which cross-referenced the key subject areas with an earlier categorisation of the same errors using GEMS. The numbers of errors in each category were used to identify patterns of error. RESULTS: Eight key subject areas were identified; hospital systems, prioritisation, treatment, ethical principles, procedural skills, communication, situation awareness and infection control. There was a predominance of rule-based mistakes in relation to the key subject areas of hospital systems, prioritisation, treatment and ethical principles. In contrast, procedural skills, communication and situation awareness were more closely associated with skill-based slips and lapses. Knowledge-based mistakes were less frequent but occurred in relation to hospital systems and procedural skills. CONCLUSIONS: In order to improve the management of acutely unwell patients by junior doctors, medical educators must understand the causes of common errors. Adequate knowledge alone does not ensure prompt and appropriate management and referral. The teaching of acute care skills may be enhanced by encouraging medical educators to consider the range of potential error types, and their relationships to particular tasks and subjects. Rule-based mistakes may be amenable to simulation-based training, whereas skill-based slips and lapses may be reduced using strategies designed to raise awareness of the interplay between emotion, cognition and behaviour.

Exploring error in team-based acute care scenarios: an observational study from the United kingdom.

PURPOSE: To investigate the errors made by junior doctors (first year after primary medical qualification) in simulated acute care settings, using (and, for some purposes, amplifying) a previously published generic error-modeling system (GEMS). Possible error types were skill-based slips and lapses, rule-based mistakes, knowledge-based mistakes, and violations. METHOD: In August 2010, 38 junior doctors participated in high-fidelity simulated acute care scenarios in NHS Lothian, Scotland. Each video-recorded scenario was immediately followed by an audio-recorded debrief that encouraged articulation of underlying cognitive processes. Two researchers used evidence from the scenario, debrief, and field notes to determine which errors were attributable to a single underlying cause. In such cases, the errors were coded by template analysis into the GEMS framework. Errors for which a single cause could be identified but which did not fit the framework were coded inductively. RESULTS: A total of 243 errors were identified, with sufficient evidence available to identify a single cause in 190. Skill-based slips and lapses, rule-based mistakes, and knowledge-based mistakes were all clearly identified within the data. Two error types not originally included in the GEMS framework were identified: compound errors and submission errors. CONCLUSIONS: Amplification of GEMS provides a valid framework for categorization of the errors made by junior doctors in simulated acute care contexts. In addition, the amplified framework may be transferable to other, team-based contexts. An improved understanding of the knowledge and skills that are most vulnerable to each specific type of error will allow tailored educational strategies to be developed.

The preparedness of UK graduates in acute care: a systematic literature review.

PURPOSE OF STUDY: The ability to recognise acutely unwell patients and to instigate generic resuscitation is essential for all newly qualified doctors. The aim of this review is to synthesise recent work examining the perceived preparedness of UK medical graduates in acute care, relative to the other outcomes detailed in Tomorrow's Doctors (2009). STUDY DESIGN: A systematic literature search was performed using five databases. It sought literature related to preparedness in acute care and other Tomorrow's Doctors outcomes from the perspectives of the graduates themselves and their professional colleagues. Two researchers undertook data extraction and quality scoring, and preparedness ratings in each outcome were mapped to a generic rating scale to allow comparison between studies. RESULTS: 256 articles were recovered, with 10 included in the final analysis. The 10 articles suggested that graduates perceive themselves to be least well prepared in acute care and prescribing. Their professional colleagues perceive them to be less prepared in acute care than in any of the other outcomes and perceive preparedness in acute care to have declined since the first publication of Tomorrow's Doctors. Furthermore, there is evidence that preparedness in acute care is an area of concern for UK graduates. CONCLUSIONS: The assimilation of evidence in this review suggests that recent changes in UK undergraduate training, while improving preparedness in some areas, may have neglected acute care. While not a good surrogate for actual preparedness, perceived preparedness is important in influencing the behaviour of new graduates and therefore warrants further consideration.

Understanding the behaviour of newly qualified doctors in acute care contexts.

CONTEXT: A particularly onerous aspect of the transition from medical student to practising doctor concerns the necessity to be able to rapidly identify acutely unwell patients and initiate appropriate resuscitation. These are skills in which many graduates feel poorly prepared and are considered by some to be best learned on the job. This constructivist study investigated the factors that influence the behaviour of junior doctors in this context and initiated the development of a framework that promotes understanding of this important area. METHODS: Focus groups involving 36 clinicians with a variety of clinical experience were conducted and analysed using a qualitative, grounded theory approach. The complex relationships between emergent themes guided the development of a framework that was refined and validated by further interviews with participants. RESULTS: Six main themes, grouped under three broad headings, emerged from the data: 'transferring knowledge into practice' and 'decision making and uncertainty' (cognitive challenges); 'acts and omissions' and 'identity and expectations' (roles and responsibilities), and, finally, 'the medical hierarchy' and 'performing under stress' (environmental factors). The framework presented within this paper illustrates the complex relationships between these factors. CONCLUSIONS: Although the potential of metacognitive strategies to reduce medical error is acknowledged, the framework promotes looking beyond the individual to consider the contributions to patient safety of identity issues, role uncertainty and the hierarchical clinical environment. A more distributed approach to situation awareness may help junior doctors to better tolerate complexity and uncertainty. The efficacy of simulation as an educational strategy may be improved by finding ways to recreate the hierarchical and stressful environment in which junior doctors practise. Junior doctors should be aware of the impact of affect and emotion on behaviour, and clinical supervisors should strive to ensure that roles and responsibilities are explicitly discussed.