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Use of In Situ Simulations to Identify Barriers to Patient Care for Ad Hoc Multicultural and Multidisciplinary Teams in Developing Countries

Nicole Shilkofski1,2,3, Elizabeth Hunt1,2,3

Department of Anesthesiology and Critical Care Medicine1 , Department of Pediatrics2 and The Johns Hopkins Medicine Simulation Center3, Johns Hopkins University School of Medicine

Aims:  1) To use simulation to identify from an emic perspective team and environmental factors posing barriers to patient care within unfamiliar settings by ad hoc teams with members from different countries, practice settings and cultural backgrounds 2) To understand how in situ simulations in resource-constrained settings in developing countries may impact team awareness and communication in order to improve patient safety

Background:  Key principles in crew resource management (CRM) include knowing the environment, effective communication and exercising leadership.  Cultural differences create obstacles to effective teamwork that can prevent effective CRM practice.  This is particularly salient in ad hoc teams tasked to function in unfamiliar and resource-constrained settings in the developing world, such as the setting that exists during medical and surgical mission volunteer work.  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.

Methods:  A qualitative phenomenological study was conducted in 11 different countries in Africa, Asia, South America, Caribbean and Eastern Europe during medical and surgical missions in these countries over the course of two years.  Data from observations of 42 simulated emergencies were coded for thematic analysis.  Key informants representing different training backgrounds, practice settings and cultures were interviewed regarding perceived benefit of simulated “mock code” scenarios prior to commencement of patient care by volunteer teams.  Observers also made note of any key practice changes that resulted from team participation in simulated scenarios that impacted patient safety goals designated within WHO surgical safety patient checklists.

Results:  Coding of observations 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 of lack 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, delineation of specialty-specific roles in an emergency situation, and delegation of specific tasks within the WHO surgical safety checklist.

Conclusions:  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 can also facilitate emergency management planning that may ultimately result in improvements in patient safety.




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