Excellence in performance and stress reduction during two different full scale simulator training courses: A pilot study

In their paper, Marshal et al. sought to measure the effect of a checklist on the technical and non-technical skills of doctors during a simulated airway problem 1. While the Anaesthetists’ Non-Technical Skills (ANTS) instrument they used has been validated in simulated practice 2, 3, we are not aware of any published data relating to routine clinical practice. This is surprising, since the assessment of non-technical skills is now a routine part of anaesthetic training, and failure to demonstrate appropriate non-technical skills may lead to a failure to progress through anaesthesia training 4. In contrast, the UK aviation industry introduced standardised non-technical skills training instruction in 1998, in the form of ‘crew resource management’, with later development into NOTECHS (non-technical markers). With institutional research and ethical approval, we have recently compared the non-technical skills of 21 volunteer non-consultant anaesthetists (seven female, 16 male) in three hospitals, measured using both normal subjective clinical assessment and ANTS assessment. All clinical supervisors had completed formal, summative assessments on a regular basis, but were not formally trained in the use of the ANTS tool. Out of a maximum score of 16, the median (IQR [range]) overall rating was 14 (12–16 [12–16]). Nine anaesthetists scored 16, with all supervisors scoring at least one subject as 16. Within the four main categories of task management, teamworking, situation awareness and decision making, all ratings were either good or acceptable with no ratings of poor or marginal. There was a median (IQR [range]) of 4 (0-5 [0-20]) positive and 0 (0–1 [0–4]) negative comments per case. We did not expect ANTS scores to be so uniformly high, and believe it unlikely that almost half of study anaesthetists performed at an ‘exemplar’ level with no subject exhibiting poor behaviour. While it is possible that the ANTS scoring system is invalid or that the raters failed to observe correctly, the literature suggests this is unlikely 2, 3, 5. However, that an ‘acceptable’ rating was provided for six anaesthetists despite their failure to complete the mandatory surgical safety checklist, and for 21 anaesthetists despite negative comments’ being offered by assessors, suggests a lack of clarity among assessors in this study about how to apply the standards objectively within the close social interaction that exists between student and assessor 6. These data reinforce the absolute necessity for the assessment of non-technical skills to be undertaken by properly trained assessors 3, 5.

Chapter 19 - The Military Perspective

Anesthesiologists and otolaryngologists are specialists who share overlapping patient considerations because of the proximity of the surgical field and airway. Although many surgical environments benefit from a collegial team dynamic, the interdisciplinary otolaryngologic environment mandates collaboration from anesthesiologists and otolaryngologists for optimal patient outcomes1. Patients undergoing head and neck surgery are at high risk of potentially devastating events if the airway anatomy is distorted secondary to pathologic conditions or previous surgeries. Although many ENT Anesthesia fellowship programs provide exposure to a wide array of clinical cases and development of airway technical skills, the current simulation literature suggests that training programs focus on improvement of procedural skills in silo2–4. However, this is not optimal for prevention or management of high stress situations where crises resource management (CRM) and interdisciplinary team dynamics can affect patient outcome. We would like to encourage every ENT Anesthesia and Surgical training program to consider introducing a comprehensive simulation-based educational component to ensure proficiency in CRM, communication skills, and leadership skills to better manage the rare and critical cases. The use of simulation for interdisciplinary training amongst anesthesiologists, surgeons, and nurses offers flexibility, preserves realism, and enhances patient safety, which makes it ideal for education and assessment of practitioners, regardless of level of training. A wide variety of simulation technology exists with differing degrees of complexity and fidelity that can be used to advance technical skills. Two major classes are part-task trainers and whole-task trainers. Part-task trainers include simple models designed for a specific task. They vary from animal models and mannequins, to more advanced screen-based computer interface. Examples of airway trainers such as the Laerdal adult airway mannequin are capable of mask ventilation, supraglottic airway placement, fiberoptic intubation, as well more invasive procedures of cricothyrotomy and tracheostomy. Slightly more advanced part-task trainers include bronchoscopy devices such as GI-BRONCH Mentor (3D Systems, Littleton, CO) which provide screen-based simulation coupled with tactical psychomotor mechanics. Part-task trainers are important for clinicians to build fundamental skills that can be translated into proficiency in clinical practice. For example, studies have shown a faster acquisition of direct laryngoscopy and improved psychomotor skills on fiberoptic intubations when practiced initially on part-task trainers5,6. In contrast, whole-task trainers (Laerdal SimMan 3G, CAE HPS) are full-scale patient simulators with advanced computer-driven technology and human-modeled physiology that can be altered for desired clinical scenarios. When whole-task trainers are combined with standardized patients and part-task trainers, a hybrid learning environment can be created to incorporate high-fidelity simulation scenarios involving technical as well as nontechnical skills. Team training in the form of interprofessional education (IPE) and interprofessional learning (IPL) is critical for patient safety in the operating room in general, but more so in head and neck cases due to the shared working environment between otolaryngologists and anesthesiologists1. IPE refers to 2 or more professions learning with, from and about each other to improve collaboration and the quality of care, whereas IPL is learning that arises from interaction between members of 2 or more professions7. Rare and potentially disastrous ENT scenarios can be created and implemented, requiring interdisciplinary teamwork and communication for proper patient care. For instance, an in situ simulation course (one that uses actual clinical resources and equipment) at Boston Children’s Hospital teaches teamwork, CRM, and decision-making of high-risk, low frequency airway emergencies to a team of otolaryngology residents, anesthesia trainees, and operating room nurses8. Scenarios such as foreign body aspiration, the bleeding airway, or airway obstruction requiring a surgical airway can be simulated using a hybrid approach with mannequins and standardized patients. These complex educational modules can enhance the learning process and joint coordination of care for both specialists9,10. A rarer emergency includes the airway fire scenario, which not only tests the nontechnical skills and treatment, but also introduces the “fire triad” (oxidizer, ignition source, and fuel), and creates heightened awareness of anesthetic and surgical management to avoid such a disaster11–13. In situ simulations can also be conducted before implementation of new protocols to assess efficiency, to identify disruptions to workflow, and to evaluate various aspects of patient care such as systems-based errors and integration errors. At Johns Hopkins, an interdisciplinary difficult airway response team was created to manage hospital wide airway emergencies and incorporation of in situ simulations proved to be an invaluable tool to probe the system and to identify defects in resources14. A comprehensive, high-fidelity simulation curriculum incorporated into the ENT anesthesia fellowship allows the refinement of psychomotor skills for advanced airway as well as development of nontechnical management skills. Furthermore, when deliberate stressors are added to a fully immersive simulation involving participants in anesthesiology, otolaryngology and nursing, an opportunity is provided to enhance IPE and to facilitate multidisciplinary collaboration. A study conducted on advanced cardiac life support skills showed that adding extreme emotional stressors to a simulated scenario demonstrated an increased retention of skills and knowledge, as well as better performance of advanced cardiac life support15. Another study revealed that a negative outcome to the patient during simulated independent practice led to better retention of clinical skills upon retesting as compared with those who performed in a simulated supervised practice (where a superior helped intervene to prevent the negative outcome)16. The debriefing period that follows allowed the participants to reflect on individual practice and teamwork to identify weak links and areas of improvement for patient safety and care. Simulation has been used successfully as an assessment tool for medical students, residents, nurse anesthetists and practicing anesthesiologists17–20, as well those deemed incompetent21,22 or those retraining to reestablish competence23. Simulation is an ideal technique for fellowship training, education, and assessment of technical and nontechnical skills, especially in the subspecialty of ENT Anesthesia where unfamiliarity of rare ENT emergencies and crisis situations can have catastrophic implications. We urge that every ENT Anesthesia fellowship consider developing and incorporating simulation as part of the fellowship curriculum. Conflict of interest disclosures The authors declare that they have no financial conflict of interest with regard to the content of this report.

This review provides the state of crew resource management (CRM) training evaluations since the E. Salas, C. S. Burke, C. A. Bowers, and K. A. Wilson (2001) review and extends it to areas beyond aviation cockpits. Some critical evaluation needs in CRM training are also covered. Because of the purported success of CRM training in aviation, other high-consequence domains have begun to implement CRM training for their workforces. However, the true impact of CRM training in aviation and these other domains has yet to be determined. Using D. L. Kirkpatrick's (1976) framework for evaluating training (i.e., reactions, learning, behavior, and organizational impact), we reviewed 28 published accounts of CRM training to determine its effectiveness within aviation, medicine, offshore oil production and maintenance, shipping/maritime, and nuclear power domains. Findings indicate that CRM training generally produced positive reactions from trainees; however, the impact of training on learning and behavioral changes suggest mixed results across and within domains. Furthermore, and as was found by Salas, Burke, et al. in 2001, we cannot ascertain whether CRM has had an impact on the organization's bottom line (i.e., safety). Based on the results, there are several critical needs that the CRM training community must address before CRM training can have the desired impact on safety: a mandate, access to data, and resources. As CRM training expands to organizations beyond aviation, it is critical that its impact be understood such that it can be improved and achieve the intended results.

WOCRM is based on the Crew Resource Management (CRM) training program developed in the aviation industry in the 1980's. It is an attitudinal and behavioural training methodology; used to continuously engage the crews in repetitive, hands on and interactive exercises and simulations, providing structured feedback to develop each crew members’ non-technical skills. The training was first developed for airline cockpit crews in the 1980's and has since flourished within commercial and military aviation, mining and medical industries. A review done for Qantas by David Hainsworth, (Briefing to Qantas safety management, 2000) indicated that 96% of their LTI's root causes were behavioural in nature. According to Edkins (2002), it follows that if we agree that the focus of CRM is to modify and reinforce effective safety Behaviour, it is reasonable then to assume that LTI's will be reduced. If LTI's are reduced, so too then is the costs associated with them, which in Oil and Gas can go into the billions and so a very good Return on Investment (ROI). Focusing on Oil and Gas, the IOGP reports clearly indicate that Well Operations Crew Resource Management (WOCRM) training is required and that it should be incorporated into the mandatory International Well Control Forum (IWCF) and International Association of Drilling Contractors (IADC) Well Control Training. This is all well and good, however, if anything is to be learned from Dr Graham Edkins, (The state of the nation: How mature are HF/NTS programs within the Australian Airline Industry?, 2012) training alone is not enough. From a psychological standpoint, to change or correct a Behaviour takes 66-270 days of repetition and constructive feedback. Therefore, the new Behaviour, process or procedure must be repeated for at least 3 months, to ensure that the Behaviour or procedure will in fact be applied when needed, especially in a stressful situation. This then implies the need to add coaching techniques to the methodology, which this paper will introduce. The major benefit to Oil and Gas, is that all of the techniques mentioned herein have already been created and developed, and our Industry simply has to apply the lessons learned from those that are more advanced, to create a continuous personal development methodology to reduce Lost Time Incidents (LTI's) caused by human error, which would have a potentially massive effect on the financial loss associated with these errors, concluding that this methodology could have a very impressive Return on Investment (ROI) for companies large and small.

One challenge for applied training research is to effectively balance the need to deliver a product to meet operational requirements with the need for scientific rigor. In this article we document an applied research effort and offer lessons learned from balancing science and operational necessity while meeting naval aviation's crew resource management (CRM) training requirements. Specifically, in 1990, 60%-80% of all accidents in naval aviation were due to human error. In an effort to reduce accidents attributable to poor aircrew coordination, a program of training research was conducted. Research involving empirical and field investigations was performed and the result was strategies, methods, and tools that supported CRM training. The success of this applied training research resulted in a methodology for the design, development, and evaluation of CRM training programs for naval aviation. The methodology was used as the basis for required annual CRM training throughout naval aviation. This article discusses the (a) operational need, (b) research effort, (c) operational transition, and (d) lessons learned.

Research has shown that lack of non-technical skills (also called, Crew Resource Management – CRM) contributes to most personal and process safety incidents in high-risk industries. Situational awareness in the most influential non-technical skill. Authors developed a disruptive program to generate situational awareness competencies and improve non-technical skills of front-line employees. The program is called: Permanent Attention. It combines best practices adapted from high-risk industries and industrial psychology science to generate statistically significant improvements in situational awareness competencies through a sustainable approach. The paper shows real case applications from two organizations where the Permanent Attention program has generated significant improvement in the participants’ situational awareness competency and non-technical skills (CRM) acquisition and retention. The program is executed with the learner at the centre of the process. The Situation Awareness Global Assessment Technique (SAGAT, Endsley, and Garland, 2000) is used to measure the levels of situational awareness competency before and after the training, to determine the impact achieved through the program. The ‘Repeated measures – ANOVA’ statistic model is used to scientifically demonstrate the significant impact of the process in the three elements of situational awareness: Attention, Comprehension and Anticipation. The training sessions in-between SAGATs contain theoretical information and practical exercises that equip the participant(s) with fundamentals. Exercises for each element of the situational awareness have been designed to obtain optimal skills. To complement the practice of non-technical skills, employees are exposed to simulations of critical operational situations, so they can demonstrate their leadership, communications, teamwork, decision-making skills in group and learn how to manage stress in such situations. The levels of situational awareness competencies are periodically monitored via practical field-based SAGAT exercises after the training, to ensure a sustained improvement in the participants’ competencies. The feedback provided immediately after each SAGAT is key to let the participant focus on the element(s) of situational awareness that require improvement. Once the feedback is received, the participant is requested to self-evaluate her level on each element of situational awareness. This reinforces self-consciousness and encourages a sense of commitment to improve by conviction, not by imposition. This novel methodology gives the organization a clear metric on the return on the investment the program offers and allows very specific interventions to improve individual and group level non-technical skills across the organization. A truly disruptive method. The paper shows how the Permanent Attention instructional design combines Endsley's research from the aviation and nuclear industries, with Knowles’ andragogy (2015) theory to achieve competency acquisition and retention. Novel approaches such as the SAGAT, are used with scenarios that are familiar to the target population. Participants’ levels of situational awareness competency are measured before and after the training to determine whether a statistically significant impact was achieved through the program. Permanent Attention has been implemented in organizations with a wide range of maturity. Case-studies are presented to illustrate the process, results, and limitations in two leading drilling companies, in which 60 to 70% of incidents had situational awareness as a contributing factor, over last five years. The implementation of the program has brought statistically significant improvements in the competency of employees and the pilot in Colombia has shown early signs of accident reduction.

The US Navy's Crew Resource Management (CRM) training programme has not been evaluated within the last decade. Reactions were evaluated by analysing 51,570 responses to an item pertaining to CRM that is part of a safety climate survey. A total of 172 responses were obtained on a knowledge test. The attitudes of 553 naval aviators were assessed using an attitudes questionnaire. The CRM mishap rate from 1997 until 2007 was evaluated. It was found that naval aviators appear to think than CRM training is useful, are generally knowledgeable of, and display positive attitudes towards, the concepts addressed in the training. However, there is a lack of evidence to support the view that CRM training is having an effect on the mishap rate. As the next generation of highly automated aircraft becomes part of naval aviation, there is a need to ensure that CRM training evolves to meet this new challenge.

Due to the success of CRM training in aviation at improving the knowledge, attitudes, and skills of trainees, CRM training has been adapted and implemented in a number of domains beyond aviation. In this paper, we chose to focus on the health care community's efforts because of the high risk and frequency of errors in this domain. Therefore, the purpose of this paper is threefold. First, we turned to the literature to identify and gather the training evaluation efforts being conducted in the health care community. Fifteen studies were identified. Next, we analyzed the research to determine the effectiveness of the CRM training efforts. As the effectiveness of training was not as positive as hoped, we conclude with several observations that may be hindering the effectiveness of their training efforts.

Crises in the operating room, often resulting from human factors, endangers patient safety. Simulation-based training to develop non-technical skills shows promise in managing these crises. This review examines the simulation techniques, targeted healthcare professionals, non-technical skills, crisis scenarios, and evaluation metrics used in operating room crisis management training. Systematic review. MEDLINE, APA PsycInfo and Web of Science databases were searched for peer-reviewed articles published between January 2004 and March 2024. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review protocol has been registered on the Open Science Framework (OSF) (https://osf.io/7bsc8). The inclusion criteria were as follows: (1) The study population comprised healthcare and medical professionals or students; (2) the intervention involved a simulated learning or training experience; (3) the outcomes focused on non-technical skills or crew resource management; (4) the training setting was the operating room (simulated or real); and (5) the learning scenarios depicted a crisis or an adverse event. This systematic review identified 29 eligible articles. The findings highlight the predominance of high-fidelity simulations, primarily targeting medical staff rather than nurses or other healthcare professionals. Training focused on communication, teamwork, situation awareness, problem solving, and decision making, with scenarios mostly addressing patient deterioration. Assessments reached up to Kirkpatrick's Level 3, demonstrating a positive training impact through learners' reactions and learning metrics rather than behavior and organizational results. Despite their effectiveness, current training practices exhibit limitations. Incorporating nurses and other paramedical staff in interprofessional training, as well as emphasizing team-related scenarios and evaluating behavioral changes in practice, could enhance training effectiveness. This has implications for interprofessional healthcare education and skills transfer to real-world settings, ultimately improving patient safety.

In-Situ Simulation for Intensive Care Nurses During the COVID-19 Pandemic in Italy: Advantages and Challenges

Surgery in Safe Hands

Chapter 12 - The Migration of Crew Resource Management Training

Introduction
\nSimulation training is widely adopted in clinical medicine. Simulated environment provides a safe condition for participants to practice without any harm inflicted on patients. Within the spectrum of clinical anaesthesia, simulation mannequin was first developed in 1960. The first journal article with description about the use of simulator to teach intubation to anaesthesia residents occurred in 1969. The first report about simulated anaesthesia training was in 1988. Since then, there has been a flourishing trend of adopting this simulation training in clinical anaesthesia, across various subspecialties including obstetric anaesthesia, cardiac anaesthesia. For individual perspective, simulation training expanded beyond skill development into non technical skill training. 
\nThis article is to review the impact of simulation training for individual development for anaesthesia residents or trainees. The aim is to evaluate the evidence of simulation training on individual anaesthesia resident performance and improvement on patient outcome. As a result, more vigorous use of simulation is adopted in modular subspecialty anaesthesia and also non-technical skill training for residents.
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\nMethods
\nA search of literatures through search engines of Pubmed, Google Scholars, EMBASE, Cochrane library for ‘Simulation for training of clinical anaesthesia’ was done. After limit the search for English language and past 10 years, there are 223 articles. With appropriate exclusion criteria, 25 articles are selected for detail evaluation. 
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\nResults
\nSimulation has good effects in various aspects. For various anaesthesia subspecialties, simulation-based training can improve trainees’ confidence and capability in handling rare but life-threatening peri-operative crises. For assessments, simulation is an essential part of Israeli Board Examination in Anesthesia with good discriminating power. For technical skill development, simulation-based training can reduce residents’ time requirement to perform cricothyroidotomy and improve successful rate of central line insertion. The specific skill developed can retain for long period of time such as 12 months. For non-technical skills, there are conflicting results in behavioural scores. For patient safety and outcome perspective, there lacks the result from individual simulation-based training study. 
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\nConclusions
\nSimulation in anaesthesia residents training is a worldwide practice. These simulation training allow residents to have exposure in various anesthesia subspecialty including cardiac, obstetrics, liver transplant. There are specific technical and non-technical skill development. Individual performance particularly time to complete cricothyroidotomy and confidence, understanding of procedures and anatomy by residents are also enhanced. Thus, simulation should be allocated more proportion of anaesthesia resident training in Hong Kong. Although there remains no study showing better patient outcome after simulation-based individual training, future studies should be done to confirm such presence and degree of association with simulation training.

IntroductionEmpirical data on the effectiveness of BRM trainings is still sparse and as far as studies were published, not very encouraging. Both O’Connor (2011) and Rottger, Vetter & Kowalski (201...