Nicole Shilkofski, M.D., M.Ed.

1. A Global Context:Uncovering Cultural Perspectives to Improve Team Functionality and Patient Safety Nicole Shilkofski, M.D., M.Ed.

2. No Disclosures or conflicts of interest

3. Objectives Describe the development of a qualitative research platform using simulation in developing countries Discuss the impact of culture on ad hoc team communication and team functionality and how simulation assisted in improving communication and function Demonstrate that culture and language play a role in crisis resource management (CRM) principles

4. “Anthropologic Simulation” Sociocultural impact of simulation Simulation as an ethnographic method of assessing facilities and teaching trainees in under-resourced settings in the developing world

5. What is culture? Medicine as its own culture with its own language Differences in “language” and focus also varies with specialties within medicine Cultural differences in different disciplines

6. How does culture impact decision making? Can and/or should simulation change culture? Can simulation act as a way to highlight cultural differences and cultural impact on teams? Can simulation therefore impact decision making in multicultural groups?

7. Introduction- The Problem and its Significance 10 million annual deaths in children under age 5 in less developed countries 80% of these are estimated to be avoidable (Jones et al, 2003) Improvement in education surrounding emergency management of pediatric patients is key factor Currently, few programs exist to address this need or remediate the existing educational deficits Programs must take into account cultural and resource specific considerations if they will be effective

8. ~ 10 million children die each year before reaching their 5th birthday Global Health Threats to Children

9. Similar top 10 causes of child death in both high and low/middle income countries Global Health Threats to Children 80%of child deaths occur in low/middle income countries

10. InfantMortality Rates www.worldmapper.org

11. Nurses Working www.worldmapper.org

12. Physicians Working www.worldmapper.org

13. Introduction Teams caring for pediatric patients in developing world are often: Ad hoc Inexperienced in pediatric care Under-resourced Interdisciplinary Multicultural Subject to increased cognitive load Therefore face multiple barriers to care

14. Introduction Decision making and cognitive processes of clinicians in under-resourced settings not well understood Barriers to team functionality in under-resourced settings not well defined Both must be better elucidated in order to design effective educational interventions

15. Proximal Study Aims • To identify from an emic perspective team and environmental factors posing barriers and latent threats to patient care by ad hoc interdisciplinary and multicultural teams • To understand how in situ simulations in these contexts may impact team cognition, awareness, communication and naturalistic decision making

16. Ultimate Study Aims Observations of simulated emergencies lead to identification of barriers to patient care Inform design of educational interventions Improve cognitive outcomes, affective outcomes, teamwork processes and performance outcomes Improve care of pediatric patients in developing countries or austere environments

17. Definition of Terms • Ad Hoc Teams • In Situ Simulation • Naturalistic Decision Making Model (NDM) • Recognition Primed Decision Model (RPD)

18. Decision Making Processes • NDM is means of studying how individuals and teams make decisions and perform cognitively complex functions in demanding situations(Klein, 2008) • RPD model is paradigm for clinical decision making that includes perception and recognition of situations marked by time pressure, uncertainty, vague goals, high stakes, changing conditions and varying degrees of experience(Lipshitz, 2001)

19. Yes

20. Literature Review- Cognitive Complexity of Pediatric Care • Increased task complexity in pediatrics due to variability of age/size impacting dosing, equipment selection and other factors= increased cognitive load (Luten et al, 2002) • Design of systems allowing more attention on clinical appraisal than calculations • Range of physiologic, psychologic, psychosocial /cultural factors impacting clinical care (Bishop, 2004)

21. Literature Review- Situational Awareness and Shared Cognition • Clinicians perform better as members of teams who have shared cognition/ same mental model of situations and decision making processes (Hunt et al, 2007) • Multidisciplinary team training using simulation for ad hoc teams in Sub-Saharan Africa and India show improved performance and knowledge (Bergman et al, 2008; Tchorz et al, 2007)

22. Methods- Study Design • Qualitative Design- Ethnographic field approach • Klein’s model of NDM as framework to construct and guide some interview questions • Study observations and interviews focused on: • Processes and barriers to team integration, assimilation and decision making during simulated pediatric emergencies in resource-constrained environment • Individual clinicians’ thought processes during decision making in this environment

23. Methods- Role of Researcher Research team= 2 clinicians with clinical and teaching experience in developing countries and simulation methodology Facilitated simulation scenarios Conducted observations and collected field notes Interviews with key informants

24. Methods- Site Selection • 17 sites for observation in 15 different countries as part of surgical, medical or educational missions: Thailand Kosovo India Uganda Kenya Papua New Guinea Honduras Cuba China Guyana Egypt Vietnam Russia Nepal Philippines

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26. Methods- Study Participants • Subjects of observations = teams caring for children in medical and peri-operative environments during 42 discrete simulated emergency situations • Team members represented 25 countries and 19 linguistic origins • Key informants= 3 clinicians per hospital selected for interviews (39 total interviewees) • Represented multidisciplinary decision-makers or team leaders from study observations • Key informants represented 15 different countries and 12 linguistic origins

27. Methods- Overview of Data Collection Strategies Simulations and observations of care teams occurred on wards, ER, ICU, PACU and OR Field notes and audio/video recording when feasible Observers developed categories to code and classify data Semi-structured interviews designed to understand team member-perceived barriers to patient care, “lessons learned” from simulations, NDM proceses

28. Methods- Observations of Simulated Pediatric Emergencies • Scenarios using low fidelity mannequins designed to focus on commonly encountered issues/major contributors to pediatric morbidity: • Fluid resuscitation in hypovolemic or hemorrhagic shock • Hypoxia and respiratory distress with subsequent dysrhythmia

29. Results Results of observations and interviews separated by thematic categories derived by coding process Theory/hypothesis development as a result of coding process

30. Theme 1: Communication and Language Barriers Impacting Team Situational Awareness Medical errors resulting from language barriers or communication breakdowns Impairment in shared understanding of situation Reversion of non-native English speakers to native language in emergency situations Creation of communication “islands”

31. Theme 2: Impact of Culture on Team Hierarchy Conceptualization of team hierarchy and organization dependent on culture Differing models of leadership/followership Reluctance to question or challenge leader/authority universal but more prominent in some cultures Leader communication style dependent on culture of origin- collectivistic vs. individualistic Culture impacting concept of gender egalitarianism

32. Theme 3: Identification of Equipment and Logistic Barriers to Patient Care Absence of necessary medications Expired medications in crash box Inadequate oxygen tubing Lack of availability of appropriate sized equipment for children Lack of staff knowledge of location and functionality of emergency equipment All identified as latent threats to patient care

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35. Theme 4: Lack of Systematic Emergency Procedures Teams lacked formal systematic procedure in event of patient decompensation/ emergency Different organizational norms for these systematic procedures Led to lack of clear role delineation and team leadership during emergency

36. Theme 5: Improvement in Shared Cognition and Resource Awareness through Simulation Participation Improvement in team “executive consciousness” and work flow with progressive simulations Improved functionality due to awareness of resources (or lack of resources) with contingency plans made Shared mental models

37. Theme 6: Use of Recognition Primed Decision Making by Experienced Clinicians Experienced clinicians made decisions based on prior experience, intuition and Gestalt pattern recognition (heuristics) Novice clinicians reported decision making system that used mental rehearsal, deductive reasoning, exhaustive strategies Novices reported difficulty with “increased cognitive load” tasks for children E.g. Dose calculation for medications

38. Discussion and Conclusions Shared understanding necessary for ad hoc teams to learn and work together Collaborative learning promotes shared understanding Cultural impact not surprising- East/West dichotomy is documented in prior literature This dichotomy can create communication barriers during course of patient care Simulations may be able to identify and provide forum for discussion of these barriers Same CRM principles apply in resource-constrained environment with new challenges

39. Discussion and Conclusions Sim, as a form of experiential learning, can appeal to diverse learners within team construct Sim may improve team functionality areas such as membership, role, context, process and action-taking Sim can identify barriers to patient care and latent environmental threats Sim can help teams build shared cognition and common mental models

40. Conclusions- Educational Implications An educational intervention that targets multicultural, interdisciplinary teams will need to account for impact of culture and language on preferred learning and communication styles

41. Future Directions • Use of observations as a needs assessment to design simulation curricula to address: • Identified barriers as a target of educational remediation • Use of heuristic pathways and algorithms to teach novice clinicians to overcome increased cognitive load inherent in pediatric care