Multidisciplinary Crew Resource Management (CRM) in Healthcare: Attitude and Behaviour Change Associated

With Classroom and Simulation-based Training

Aims

The aims of the study were to develop a one-day, classroom-based CRM course for health

care workers; and to test the effectiveness of classroom- and simulation-based CRM training,

alone and in combination, for improving multidisciplinary teamwork attitudes and behaviours

of participants.

Background

The study examines the potential of aviation-style CRM training to improve public health

safety, by investigating attitude and behavioural changes in multidisciplinary teams resulting

from implementation of a CRM intervention in the Australian health care field. Unlike in

aviation, standalone classroom-based training is not widely used in health care simulation

settings as a prelude to simulation training.

Methods

Aviation CRM knowledge, skills and attitudes were translated to learning outcomes for health

care, based on a combination of a pre-training needs analysis, a review of the current evidence

base for team training, and an expert panel review1. The resulting competencies were

developed into a one day classroom based CRM course for health care professionals working

in complex time-critical environments in an Australian area health service. A total of 157

recruits were randomised into one of four groups, consisting of three intervention groups and

a control group. The intervention groups were then given one day of classroom CRM based

training, one day of CRM style simulation training, or both. Pre- and post-test quantitative

data were gathered on participant attitudes to working in teams, using a modified Safety

Attitudes Questionnaire (SAQ)2. Post-test quantitative data were gathered on trainee reactions

via a course critique questionnaire, and on CRM knowledge via a pencil and paper test

developed for this study. Post-test quantitative self assessed teamwork behaviour data were

also gathered, using the Mayo High Performance Teamwork Scale (MHPTS)3. Ten

participants who completed the classroom training (17%) were purposely selected with regard

to achieving a balance of experience, position and gender, and interviewed at the conclusion

of the evaluation. These interviews provided qualitative data to supplement and explicate the

results.

Results

A total of 94 doctors, nurses and midwives completed the pre-intervention attitude

questionnaire, 59 participants completed the post-intervention attitude questionnaire, and 61

participants completed the post-intervention behaviour assessment. Evidence was gathered in

support of the training using Kirkpatrick’s framework4 (see Table 1).

Kirkpatrick

evidence level4

Evidence

Level 1 reaction Positive affective and utility reactions from all classroom participants.

Reaction to simulation training not assessed.

Level 2 knowledge Improvement in knowledge following training for the classroom only

group when compared with control (two-tailed t test, P<0.002). No

significant change for other groups.

Level 2 attitude Attitude data were inconclusive and contradictory, likely due to the

study having inadequate statistical power to detect attitude changes

associated with the training.

Level 3 behaviour Improvement in behaviour following training for the classroom only

group when compared with control (two-tailed t test, P<0.009). No

significant change for other groups.

Contrary to the quantitative result, qualitative data supported the effectiveness of the training

for all intervention groups. The research uncovered qualitative evidence in support of the

importance of training health care teams in multidisciplinary groups, and the need to utilise

multi-method approaches for future classroom and simulation training studies.

Conclusions

The study revealed some positive benefits in providing classroom-based CRM training to

health care workers, but was inconclusive in whether classroom and simulation training in

combination enhance teamwork attitudes and behaviours.

1. Clay-Williams R, Braithwaite J. Determination of health-care teamwork training

competencies: a Delphi study. Int J Qual Health Care 2009;21(6):433-440.

2. Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K, Boyden J, et al. The Safety

Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging

research. BMC Health Services Research 2006;6:44.

3. Malec JF, Torsher LC, Dunn WF, Wiegmann DA, Arnold JJ, Brown DA, et al. The Mayo

High Performance Teamwork Scale: reliability and validity for evaluating key Crew

Resource Management skills. Simulation in Healthcare 2007;2(1):4.

4. Kirkpatrick DL. Evaluation of training. In: Craig RL, editor. Training and development

handbook. 2nd ed. New York: McGraw-Hill, 1976:18-1 to 18-27.