Much has been written in recent times about the need for health care to acknowledge and participate in training focused on non-technical skills which are vital in effectively managing emergency situations.
Lessons from aviation
A common frame work often used to describe these skills is Crisis Resource Management (CRM). The origins of CRM hails from the aviation industry with several disasters in the 1970s triggering investigations which discovered human error rather than equipment failure. One of the most famous was the 1972 crash of Eastern Air Lines Flight 401 which crashed in a Florida swamp, killing 99 passengers. A root cause analysis of this incident found this tragedy occurred as the crew worked to repair a burned-out light bulb and forgot to fly the plane. It almost sounds impossibly simplistic until you watch the below re-enactment.
Team building and situational awareness
Since its introduction to aviation in the 1980s CRM has evolved. Cockpit Resource Management, introduced in 1981 focused purely on the pilots. Acknowledging the narrowness of this program saw the birth of the term Crew Resource Management in the mid 1980s. As the name suggests, this second generation training encompassed all of those onboard, with the training now including team building, briefing strategies, situational awareness, stress management, decision making and breaking error chains that can cause catastrophe.By the early 1990’s CRM had once again evolved extending to other members of the wider team that shared the responsibility for aviation safety, including flight attendants, dispatchers, and maintenance personnel. CRM in the aviation industry continues to evolve with current programs now not only focusing on human error inside the cockpit but also tackling environmental and systems threats to safety, including novel error reporting systems. In health care however we seem to be stuck in CRM 1.0 and I think it’s time that we start to evolve too. CRM in healthcare has left the emphasis on “crisis”. Most courses are based in critical care areas, and focus on clinical emergencies. Debriefing then dissects the inevitable challenges of teamwork, leadership, resource allocation and communication in these high stakes, high stress events. Whilst there is value to be found in rehearsing these high risk clinical events, error reporting shows us that non technical skills continue to be a highlight in sentinel events in all areas of health care, not just during incritical care, and not only during“emergencies”. Surely it time we see CRM 2.0 in health care to reflect this?
We sell CRM under the banner of patient safety and this should be at the forefront in our everyday practice. CRM 2.0 reinforces the principles that we teach and encourage the practice of in our everyday lives as health care professionals. Not just to those in the cockpit (critical care areas) but to all members of our crew responsible for patient safety (clinician’s hospital wide). CRM 2.0 acknowledgesthat the majority of patient care occurs outside of the critical care environment, and that healthcare, no matter where it is delivered, is a high stakes, high risk activity, best delivered by teams cognizant of this, and working effectively to promote safe effective care. During stress:
“We do not rise to the occasion; we sink to the level of our training.”
It is one of my favourite quotes and I believe that the training we do is not just in the sim lab but also at the bedside every day. This is where CRM should be practiced so that when we do hit crisis point these responses are our default. Practice doesn’t make perfect, perfect practice makes perfect. We cannot expect to display a better version of ourselves under pressure unless these responses are so ingrained there isno alternative. The summary below provides some great dot points on how these principles are practically displayed. Each can be used in daily practice on some level.
ICU Outreach and CRM
In my work as an ICU Outreach nurse I have found this framework has crept outside the MET call and into my daily practice. Perhaps I should have titled this piece ‘ The Devolution of CRM ‘ as when you get back to the original focus of aviation CRM it was to focus on prevention of error rather than the pointy end of dealing with the crisis. There is more room for the practice of these principles outside critical events which may just prevent rather than assist in a crisis.
Shannon is a Clinical Nurse Consultant within the ICU Outreach Service at The Princess Alexandra Hospital, Brisbane Australia. She has lectured at undergraduate and postgraduate level with a focus on critical care nursing. Her current role also provides the opportunity to work within the simulation education service providing education opportunities for nursing staff relating to clinical assessment and non technical skills development.