Thursday, July 2, 2015

Use of In Situ Simulations to Identify Barriers to Patient Care for Ad Hoc Multicultural and Multidisciplinary Teams in Developing Countries: A Qualitative Study to Inform the Design of Educational Interventions in Under-Resourced Settings

Nicole Shilkofski, MD, MEd
Johns Hopkins University

Background: There are over 10 million annual deaths in children under age 5 in less developed countries, but 80% of these are estimated to be avoidable. Improvement in education surrounding emergency management of pediatric patients is a key factor in efforts to improve these mortality statistics in developing countries. 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. Teams that are tasked to function in resource-limited settings in developing countries often have multiple challenges, including cultural differences that can create potential obstacles to effective teamwork. It can be informative to study teams in situated context to identify remediable barriers to patient care and promote shared cognition amongst team members with different cultural norms. Itmay also be helpful to understand how experienced clinicians make decisions in emergency situations in order to inform the design of educational interventions for more novice clinicians.

Objectives: 1) To use simulation to identify from an emic perspective team and environmental factors posing barriers to patient care by ad hoc interdisciplinary and multicultural teams 2) To understand how in situ simulations in resource-constrained settings may impact team awareness, communication and naturalistic decision making

Methods: A qualitative study using an ethnographic field study approach was conducted at 6 different hospital sites in 6 countries: Thailand, Philippines, India, China, Honduras and Kenya. Observations occurred at each site over a two week period during medical and surgical missions in these countries over the course of approximately 18 months. Data from observations of 15 simulated emergencies were coded for thematic analysis. Eighteen different key informants (3 clinicians per hospital setting) representing different training backgrounds, practice settings and cultures were interviewed regarding perceived benefit of simulated "mock code" scenarios as well as their mental process in making decisions during emergencies.

Results: Coding of observations and interviews yielded common themes: Impact of culture on team hierarchy and leadership/followership models, communication and language barriers impacting situational awareness, identification of equipment and logistic barriers via simulations, identification oflack of systematic emergency procedures, differences in organizational norms amongst team members, lack of clear role delineation within teams, improvement in shared cognition through simulation participation, and improvement in resource awareness via simulations. Changes in the clinical environment implemented as a result of simulations included: systematic plans to address equipment and logistic barriers identified through simulations, development of emergency management contingency plans, and delineation of specialty-specific roles in an emergency situations. Experienced clinicians utilized recognition primed decision making strategies in making decisions during emergency situations.

Conclusion: Ad hoc teams in foreign environments face challenges in caring for patients safely, amongst them language and cultural barriers in addition to environmental and resource constraints that may be unrecognized. Engagement in situ of teams in simulations may promote improved communication, role delineation and identification of systems issues and human
factors that can be targets for remediation. Simulation may also identify barriers to patient care and latent threats in the environment as well as help teams to build shared cognition. There may be a role for training novices to use recognition-primed or algorithmic decision making strategies to improve rapidity and efficiency of decisions in resource-limited settings.