Leaders' and followers' individual experiences during the early phase of simulation-based team training: an exploratory study.

0.29 MB·English

by  Meurling, Lisbet

ORIGINAL RESEARCH
’ ’
Leaders and followers individual
experiences during the early phase
of simulation-based team training:
an exploratory study
OpenAccess
Scantoaccessmore Lisbet Meurling,1,3 Leif Hedman,3 Li Felländer-Tsai,2,3
freecontent
Carl-Johan Wallin1,3
1DepartmentofClinicalScience, ABSTRACT quality training requires deep knowledge,
InterventionandTechnology Background Agrowingbodyofevidenceshows needsanalysisofthetasktobeperformed,
(CLINTEC),Divisionof
thatteamtrainingcandevelopessentialteamskills clarification of the training objectives,
AnaesthesiaandIntensivecare,
KarolinskaInstitutet,Stockholm, andcontributetobetterpatientoutcomes. choiceoftrainingmethods,andevaluation
Sweden Currentsimulation-basedteamtraining(SBTT) and assessment of the training delivered.4
2DepartmentofClinicalScience,
programmesmostoftenincludetargetsand Traininginteamworkcomprisesgrowthin
InterventionandTechnology
(CLINTEC),Divisionof feedbackfocusedonthewholeteamand/or aspectsofcompetence,suchasknowledge,
Orthopaedics,Karolinska leader,ignoringthefollowerasauniqueentity.By skills, attitudes and behaviours (KSAB).5
Institutet,Stockholm,Sweden consideringfollowers’individualexperiences,and A prominentfeatureofmedicalsimulation
3CenterforAdvancedMedical
tailoringbehaviouraltargetsfortrainingand that leads to effective KSAB learning is
SimulationandTraining
(CAMST),KarolinskaUniversity feedback,SBTTcouldbeimproved.Ouraimwasto repetitive practice and iterative scenarios
Hospital,Stockholm,Sweden exploretheindividualexperiencesandbehaviours during one training session, or repetitive
ofleadersandfollowersduringtheearlyphaseof training sessions over time.6 Hours of
Correspondenceto
SBTT,andwehypothesisedthatleadersand high-fidelitysimulatorpracticehaveaposi-
DrLisbetMeurling,Department
ofClinicalScience,Intervention followerswouldshowdifferentresponses. tive, functional relationship with standar-
andTechnology(CLINTEC), Methods Medicalstudents(n=54)participatedin dised learning outcomes as concluded by
DepartmentofAnaesthesiaand half-daySBTTincludingthreevideo-recorded McGaghie et al.6 The minimal decisive
IntensiveCareK32,Karolinska
scenarios.Self-efficacywasassessedpretraining dose of simulation-based team training
Institutet,KarolinskaUniversity
Hospital,StockholmSE-14186, andpost-training.Foreachscenario(n=36),the (SBTT) that can add to learning, eitheron
Sweden;lisbet.meurling@ individualteamworkbehaviours,concentration, its own or for later reiteration, is
karolinska.se mentalstrainandtheteam’sclinicalperformance unknown.57Duetoresourceconstraints,a
Received1March2012 wererecorded.Datawereanalysedusingamixed numberofinstitutions offerhalf-day train-
Revised5September2012 modelallowingforparticipantstobetheirown ing, although training using onlyone, two
Accepted19November2012 controlintheirrolesasleaderorfollower. or three scenarios results in limited
PublishedOnlineFirst
Results Self-efficacyimproved.Intheroleof improvements in technical or non-
4January2013
leader,participantscommunicatedtoagreater technicalskills.8–11
extentandexperiencedhighermentalstrainand By contrast, at the very start of the
concentrationthantheydidintheroleoffollower. learning process, when training has not
Discussion Theincreasedself-efficacyenablesa yet passed the threshold needed to show
positivelearningoutcomeafteronlythree improvements in KSAB competence,
scenarios.Individualexperiencesandbehaviours studies have shown that participants’
differedbetweentheroleofleaderandthatof reactions to SBTTare extremely positive
follower.Bysheddingfurtherlightonleaders’and even after a very short training experi-
followers’individualexperiencesandbehaviours, ence.12 13 The positive reaction in the
targetsfortrainingandfeedbackcouldbe early phases of SBTT may be a token of
specifiedinordertoimproveSBTT. other individual experiences that trainers
often witness: trainees’ motivation, con-
INTRODUCTION centration, commitment and efforts in
Teamwork is of critical importance for further training.
Tocite:MeurlingL,
HedmanL,Felländer-TsaiL, patientsafety.1Effectiveteamcoordination One example of such an individual
etal.BMJQualSaf is not a case of good luck. It is trainable experience is self-efficacy, namely a belief
2013;22:459–467. through training interventions.2 3 High- in one’s personal capability to perform
MeurlingL,etal.BMJQualSaf2013;22:459–467.doi:10.1136/bmjqs-2012-000949 459
Original research
given actions, an important prerequisite for learning, in the early phase of SBTT. We therefore decided to
and a predictor for performance.14 Perceived self- undertake an exploratory study to expand the knowl-
efficacy motivates individuals to engage in pursuing edgebase.
their training goal. In general, the stronger the per- Ouraim was to explore individual experiences asso-
ceived self-efficacy, the higher the goal challenges ciated with learning and performance: we looked at
people set for themselves, and the firmer istheircom- levels of mental strain and concentration for leaders’
mitment to them. Those with high self-efficacy in a and followers’ separately during the early phase of
specifictaskaremorelikelytomakemoreofaneffort, SBTT, and their perceived self-efficacy pretraining and
andpersistlongerthanthosewithlowself-efficacy.1415 post-training. We also sampled data for training out-
It is a critical feature of successful medical simula- comes: individual behaviours and team endeavour in
tions,16 17 and hasalso been emphasised as animport- clinical performance. We hypothesized that it would
ant individual factor in demonstration-based be possible to detect changes in individual experiences
training.18 Overall, medical simulation training can early during SBTT, and that leaders and followers
improve individual as well as team self-efficacy.17 In would showdifferent responses.
this context, it should be noted that while self-efficacy
isimportantforthesuccessofatrainingprocess,there METHODS
is no consistent correlation with observed measures of Subjects
competenceandself-efficacy.17 Medical students (4th or 6th year), attending one of
Another individual experience that has been posi- three 2-week elective courses in emergency medicine,
tivelyassociated with effective teaching and learningis traumatology, or anaesthesia and intensive care, were
concentration, the skill of selectively focusing on rele- offered the opportunity to participate in the study. All
vant information in the task(s) at hand and ignoring elective courses included standardised didactic lectures
distracters, such as anxiety, mistakes and negative in top-to-toe physical examination and team coordin-
thoughts.19 20 ation training. The half-day (3.5h) SBTT was inte-
A third individual experience that might have an grated in the curriculum and was mandatory for all
effect on learning is perceived mental strain, vastly courses,whileparticipationinthestudywasvoluntary.
applied in clinical diagnostics and training.21 We For anonymous video analysis and data sampling, par-
expected that very high mental strain during training ticipants were given a personal code to label their
could jeopardise learning. scrub shirt and questionnaire. Informed consent was
Current SBTT programmes most often include obtained from all participants, and the institutional
targets and feedback focused on the whole team and/ review board approved the study (Regionala
or leader, ignoring the follower as a unique entity, as etikprövningsnämndeniStockholm,Dnr358/02).
if the leader–follower relationship exists in a vacuum.
This is a concern, as it does not fully appreciate and Simulation-basedteamtraining
model the dynamism and complexities of team leader- Students in groups of three to five attended one of 12
ship as revealed in recent research on shared half-day training sessions at the Center for Advanced
leadership.22 Medical Simulation and Training, Karolinska
Leading and following are collaborative adjustment University Hospital. Training was focused on patient
behaviours, an evolutionary strategy for solving social management in emergency medicine or traumatology.
coordination problems.23 In particular, in high- Scenarios were carried out in a re-created emergency
performing teams, some attributes and characteristics department using a patient simulator (Human Patient
associated with leaders are also prerequisites of fol- Simulator, METI Inc, Sarasota, Florida, USA). Nine
lowers; these may be referred to as, for example, standardised scenarios were designed to provide
‘good leadership’ or ‘structuring leadership’, and opportunities for training in the targets (table 1). The
‘good followership’ or ‘content-oriented leader- scenarios had the following diagnostic content:
ship’.24 25 When group members actively and inten- asthma, traumatic skull fracture due to alcohol intoxi-
tionally shift the role of leader to one another as cation, femur fracture and hypoglycaemia, traumatic
necessitated by the situation, a shared leadership femur fracture and pneumothorax, hypoglycaemia,
occurs,22 implying that team members must master heartfailureandpulmonaryoedema,ventricularfibril-
both roles in order to affect the team’s attitudes, cog- lation, diabetic acidosis, and traumatic spleen rupture
nition, behaviour and effectiveness in a positive with hypovolemia. Random samples from the standar-
manner. Since the competencies for the leader and dised scenarios were used each half-day, offering the
followers in ateam are not identical, the learning pro- studentsdifferentaccesstobasicmedicalproblems.
cesses and individual experiences ofthe two roles may The training method used was highly structured,
also differ. target-focused, team coordination training using the
To the best of our knowledge, there are no data in Crew Resource Management (CRM)-based A-TEAM
the literature concerning leaders’ and followers’ indi- programme.26 27 During training, active participants
vidual experiences associated with effective learning engaged in the scenario, while the observing
460 MeurlingL,etal.BMJQualSaf2013;22:459–467.doi:10.1136/bmjqs-2012-000949
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Table1 Targetsfortrainingandvideoanalysis
Targetsfortraining Method Analysis Note
Behaviour(1–5):
1.Takeateammemberrole TheA-TEAMprogramme,notyetvalidated,was Eachactiveparticipantwasindividuallygradedon Annotation1
2.Gatherinformationand used. afour-levelscale(poor,inneedofimprovement,
communicate Separatevideoswereusedforcalibrationof good,proficient).
3.Contributetoashared rating. Teammemberswerecategorisedaseitherleader
understandingofthesituation Activeparticipants’behaviourswereanalysed orfollower,byapplyingthebehaviouralelements
4.Makecollaborative blindbytworaters.Theyobservedthestudy for‘Leader’and‘Follower’,respectively,fromthe
decisions videosindividuallyatrandomin3minsequences. category‘Takesateammemberrole’inthe
5.Coordinateandexecute A-TEAMprogramme.Forinstance,aleadertakes
tasks theinitiativetoprovidestructureanddirect
teamworkandtaskwork,whileafollower
challengesconstructivelyandassumesassigned
responsibilities.
Clinicalperformance(6–7):
6.Timetocallforhelp,in Astandardisedmeasureofcallforhelpwas Thetimefromtheentranceofthefirstactive Annotations1
seconds(s) calculatedasaratiobydividing60swiththe participantintothescenariountiltheteamcalled and2
team’smeasuredtimeinseconds. forhelpwasmeasured.
7a.Frequencyoftop-to-toe Theaveragefrequencywascalculatedasthe Thenumberoftop-to-toephysicalexaminations Annotations1
examinations(n×h−1) numberofexaminationsdividedbythelengthof theteamcompletedinascenariowascounted. and2
thescenario.Astandardisedmeasurewas
calculatedastheratiobetweentheteam’s
measuredfrequencyandthespecialistteam’s
referencefrequency.
7b.Frequencyofteam Theaveragefrequencywascalculatedasthe Asum-upincludesthepatient’spresentproblem, Annotations1
sum-ups(n×h−1) numberofsum-upsdividedbythelengthofthe clinicalbackground,vitalfunctionsandfurther and2
scenario.Astandardisedmeasurewascalculated plan.Thenumberofteamsum-upsperformed
astheratiobetweentheteam’smeasured duringascenariowascalculated.
frequencyandthespecialistteam’sreference
frequency.
Medicalmanagement(8):
8.Stabilisethevitalfunctions Timeinseconds. Thetimefromtheentranceofthefirstactive Notused(see
ofthepatient participantinascenariountilstabilisationofthe Results)
vitalfunctionsofthepatientwasmeasured.
Annotations:
(1)Twoobservers,onespecialistinanaesthesiaandintensivecare(LM),andoneseniorresearchpsychologist(LH),neitherofwhomwereinvolvedinthe
trainingprocess,analysedindividualteamworkbehaviours(Targets1–5)usingtheA-TEAMprogramme,notyetvalidated.27LMobservedclinical
performanceandmedicalmanagement.
(2)Astheninescenarioswereofdifferentcomplexityand,assuch,notcomparable,standardisedmeasuresforclinicalperformancewerecalculatedfor
eachseparatescenario.Areferenceemergencyteam,includingaseniorconsultant,aspecialistnurseandanurseassistant,carriedouteachofthenine
scenarios,generatingreferencemeasuresfor
Targets6and7.
participants reviewed the behaviours according to the (Targets 6 and 7) and individual teamwork behaviour
targets. The facilitated debriefing session was highly (Targets 1 and 5). Targets for individual teamwork
structured, including an emotional ‘blow-out’, feed- behaviour as a leader or follower were set at the
back on medical management and clinical perform- ‘good’ level in the A-TEAM programme.27 All targets
ance, active participants’ experience and observers’ were explicitly explained in didactic lectures and
views of individual teamwork behaviours and feed- demonstrated by the trainers prior to the start of the
back to active participants, and finally trainers’ con- scenarios. Target 1 was to ‘take a team member role’,
cluding remarks and recommendations for the next that is, assign roles within the team as situational
scenario.26 28 The allocation of participants to active leader or follower when there is no outside authority
and observing roles was changed in consecutive scen- present. Thus, the training focused on the situational
arios in order to take advantage of different learning leader and his/her followers, not on formal leaders or
styles. Video recordings of each scenario were saved chiefs. This issue was thoroughly approached during
for the debriefing session, and were also used for later the didactic lecture (figure 1) in which team forma-
analysis of medical management, clinical performance tion, the assignment of roles and deliberate changes in
and individual behaviour. rolesaccording totheclinical situationwerediscussed.
The participants were explicitly asked to assign roles
Targetsfortraining during the formation of the team, in the classroom,
Targets for training (table 1) combined medical man- before entering the scenario or, ultimately, at the start
agement (Target 8), the team’s clinical performance of the scenario. Thus, the assignment of the role as
MeurlingL,etal.BMJQualSaf2013;22:459–467.doi:10.1136/bmjqs-2012-000949 461
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Figure1 Flowsheetandcollecteddata.
leader or follower among the active participants was Concentration
at the teams’ discretion and not predetermined by the From a flow instrument, constructed and validated by
trainers. Chen,weselectedeightitems(Cronbach’sα>0.7)used
Due to the students’ lack of clinical competence, forassessingaspectsofconcentration(focusing,timedis-
calling for help within 60s was as one of the targets tortion, loss of self-consciousness, and telepresence).29
(Target 6) to achieve patient safety. To enable the Concentrationwasself-assessedbyallactiveparticipants
active participants to work under stress, a consultant immediately after each scenario. Scores were calculated
entered the scenario 5min after a ‘call for help’ tele- asthemeanofallitemsusinga9-pointLikert-typescale,
phone call. where1=notatall,and 9=verymuch.
Mentalstrain
Videoanalysis Mental strain was assessed by active participants
The video analysis is presentedin table 1. immediately after each scenario using the Borg CR10
Scale and the prompt: ‘Please estimate your percep-
Individualexperiences tion of mental strain during the session by putting a
Self-efficacy cross on the numbered scale’, where 0=none at all,
Participants’ self-efficacy was self-assessed at the start and 10=the strongest you have everexperienced.30
and at the end of training using a questionnaire con-
sisting of four items, where each proposal was rated Designofthestudy
on a 7-point Likert-type scale, where 1 = not true at The design of this exploratory study, including the
all, and 7 = very true.28 The self-efficacy score was flow of data sampling and lost data, is presented in
calculated asthe mean value ofall items. figure 1.
462 MeurlingL,etal.BMJQualSaf2013;22:459–467.doi:10.1136/bmjqs-2012-000949
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Poweranalyses RESULTS
Individualbehaviour All 54 students, 26 men and 28 women (23–47years
If40% of thesubjectsimprove,and10% deterioratein of age), attending the elective courses in emergency
the behaviour ‘gather information and communicate’ medicine (n=30), traumatology (n=18), or anaesthe-
(Target2)fromscenariosI–III,therewillbe80%power sia and intensive care (n=6), agreed to participate in
todetectthisdifferenceinproportionswitha0.05two- this study. Videos from 36 scenarios were analysed.
sidedsignificancelevelwhenthesamplesizeis46. All students participated in three scenarios, alternating
as active participants and observers. The scenarios
Individualexperience were numbered I, II and III chronologically, giving
A power calculation revealed that 2×25 subjects
one set of three scenarios for each of the 12 half-day
would provide 80% power to detect a variance of
training sessions.
0.065 among the means of the two levels, self-efficacy
start and end (the difference between the levels is
Videoanalysis
0.50), assuming that the between-groups (gender)
Medicalmanagement:Target8
error term is 1.47, the within-groups error term is
In no scenario were students able to stabilise vital
0.85, the measure of ‘sphericity’ of the covariance
functions before a consultant arrived. Consequently,
matrix, epsilon, is 1.00, and the correlation between
Target 8 could not be used as the end point in this
the levels is 0.5 when the significancelevel is 0.05.
studyofmedical novices.
Statisticalanalysis Clinicalperformance:Targets6and7
As this was an exploratory study, and subjects were The frequency of team sum-ups, the time to call for
theirown controls, a linear mixedmodel in procedure help, and the frequency of top-to-toe examinations
Mixed in SAS (System 9.1, SAS Institute Inc, Cary, are presented in box-plots, figures 2–4. Standardised
North Carolina, USA) was used to analyse the con- variables (ratios) for ‘time to call for help’, ‘frequency
tinuous variables, clinical performance and individual of top-to-toe examinations’ and ‘frequency of team
experiences.31 This model is preferred for use with sum-ups’ were statistically analysed with respect to the
questionnaire data because it can use all the data even classification variables, team (1–12), and consecutive
if some values are missing, and all combinations of scenario (I–III). The only significant change in
categories do not have tobe fulfilled. It also takes into response to training was an improvement in the fre-
account covariance structures. quencyof sum-ups (p=0.04).
For the clinical performance (Targets 6 and 7), a
Individualbehaviour:Targets1–5
mixed model with one within-groups factor consecu-
Data for the five teamwork categories did not show
tive scenario (I, II and III) was performed. In the
any change between consecutive scenarios I, II and III
mixed model for self-efficacy, two fixed factors and
(p=0.11–0.97). Team behaviours were not influenced
the interaction between the factors were included.
The between-groups factor was ‘sex’ and the by type of course (p 0.24–0.90) or sex (p 0.33–0.98).
within-groups factor was ‘start/end’. For mental strain Both raters (p=0.00 and p=0.02, respectively) agreed
that in the role of leader (n=36 observations), partici-
and concentration, a mixed model with two
pants were rated higher on the item ‘gather informa-
within-groups factors, consecutive scenario (I, II and
tion and communicate’ than in the role of follower
III) and role (follower and leader), and one
(n=55 observations). The odds for the leader role
between-groups factor, sex, was performed. All pos-
having a higher score were over three times higher
sible interactions were also tested in this model.
than for the follower role.
A generalised estimating equations (GEE) model
with the GENMOD procedure in SAS was performed
to analyse the effect of the ordinal variables, clinical
experience (level of medical studies) and order of
training scenario (I–III), and categorical variables,
team member’s role (leader, follower) and sex
(female, male), on the two raters’ scoring of the
behavioural categories (Targets 1–5).32 With ordinal
data, the GEE approach provides cumulative logits
based on the cumulative probabilities. As all the stu-
dents participated in more than one scenario with dif-
ferent memberships, a repeated-measures design was
applied tothese data.
A probability (p value) <0.05 was considered statis-
tically significant. The SAS software was used for all
statisticalanalysis. Figure2 Timetocallforhelp.
MeurlingL,etal.BMJQualSaf2013;22:459–467.doi:10.1136/bmjqs-2012-000949 463
Original research
follower, respectively. The mean difference is calcu-
lated from the estimated mean values; the p value
refersto the difference between the two roles.
DISCUSSION
Summary
This study has explored individual experiences and
behaviours in the roles of leaderand follower, and the
teams’ clinical performance during the early phase of
SBTT.
After training in three scenarios, the participants’
individual self-efficacy improved in the absence of
changes in observable individual teamwork beha-
Figure3 Frequencyoftop-to-toeexaminations. viours. The teams’ clinical performance improved
modestly even though the medical goal was not
achieved.
Individualexperiences
In the role of leader, participants gathered informa-
No differences in individual experiences between men
tion and communicated to a greater extent, and
and women were registered.
experiencedhigher levels of mental strain and concen-
tration than they did in the role of follower during
Self-efficacy
Cronbach’s α for self-efficacy before training was the early phase of SBTT. The combination of these
differences in individual behaviour and experiences
0.87. Perceived self-efficacy increased for the whole
between the two roles demonstrates a higher degree
group from a mean (SD) of 5.15 (0.12) at the start of
of challenge in the training process of leader skills as
the training session to 5.42 (0.12) at the end. The
mean difference was −0.267 (p=0.043 (95% Cl comparedwith follower skills.33
−0.526 to −0.008)).
Thestudy’sparticularstrengths
Our study population of medical novices provided an
Concentrationandmentalstrain
Cronbach’s α for concentration for scenario I was excellent group both for observing teamwork and the
natural assignment as leader and follower, and for
0.78. Therewas no change in concentration or mental
strainoverthemaineffect,consecutivescenario(I–III). training in teamwork and the assignment of roles
The interaction between consecutive scenario (I–III) within a team. All participants acting as leader in one
scenario had a follower role in another, that is, the
androle(leader/follower)wasnotsignificantforeither
participants were their own controls regarding differ-
mental strain or concentration. In the role of leader,
ences in individual behaviours and experiences
participantsexperiencedahigherlevelofbothconcen-
between the role of leader and that of follower.
tration and mental strain as compared with the role of
Cross-training as a leader or follower may also
follower (table 2). Thus, the differences between the
increase understanding of the difficulties specific to
tworolescanbegeneralisedtoallthreescenarios.
each role, and thus, enhance learning.34
Table 2 shows the data for mental strain and con-
Mixed models allow the analysis of data in field
centration for active participants (n=46) after a scen-
studies, that is, data occurring authentically. Applying
ario. The estimated means (SE) from the statistical
a mixed model to the present data matrix is advanta-
model are presented here for the roles of leader and
geous, as these models do not demand a data matrix
that is balanced and complete, but make use of avail-
able informationin the dataset, also taking covariation
into consideration. Such models are not hampered by
heterogeneity of data, and provide the opportunity
for a sparse sampling approach. The statistical
methods used in this study were appropriate for the
dataset of continuous, ordinal and categorical data,
respectively. The size required to indicate significant
change in individual behaviour and self-efficacy was
chosen to correspond to sound clinical experience in
order not to overestimate the importance of minor
differences.
In this study, we used a multimodal approach,
recording the team’s medical management and clinical
Figure4 Frequencyofteamsum-ups. performance, together with individual teamwork
464 MeurlingL,etal.BMJQualSaf2013;22:459–467.doi:10.1136/bmjqs-2012-000949
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Table2 Dataformentalstrainandconcentrationforactiveparticipants
Roleasleader Roleasfollower
Membership
Differencein
Estimatedmean SE Estimatedmean SE estimatedmean p 95%CI
Mentalstrain(0–10) 5.88 0.38 4.31 0.27 1.57 <0.001 0.735to2.40
Concentration(1–9) 6.30 0.17 5.69 0.17 0.612 0.003 0.225to1.00
behaviours and experiences in both leader and fol- confirms and verbalises decisions, gives orders and
lower roles. We found differences between individual takes the initiative in team sum-ups. All these actions,
behaviours and experiences in the two roles during a or a ‘structuring leadership’, are accompanied by
phase when training had not yet passed the threshold intensive communication and, as such, differ between
to show improvements in behaviour. These results leaderand follower.
support those of Kraiger et al,35–37 among others, The difference in behaviours between the leader and
who proposed that training should be evaluated con- follower roles is in contrast with the lack of difference
sidering cognitive, skill-based and affective learning regarding the other four categories of teamwork beha-
outcomes to reach a more comprehensive picture of viours; in the roles of leader and follower, participants
the training process. scored at the same levels regarding ‘takes a team
memberrole’,‘contributestoasharedunderstandingof
the situation’, ‘contributes to collaborative decisions’,
Relationtootherevidence and ‘coordinates and execute tasks’. This lackof differ-
The lack of significant improvement in medical man- enceinscoringbetweentherolesofleaderandfollower
agement and clinical performance in response to is in line with recent studies on shared leadership.22
half-day SBTTin our study is in line with the findings Among others, Kunzle and colleagues have shown that
of other studies.8 9 Teamwork behaviour was graded better performance and results in a team are associated
for the entire teams or individually for leaders, and with an even distribution of leadership behaviours
limited changes were reported in early phases of betweenteammembers.2542TheCRM-basedA-TEAM
SBTT.10 11 The same lack of change observed in indi- programme used in the SBTT in this study emphasises
vidual behaviour in response to SBTTalso applied to that leaders should structure teamwork, and followers
individualfollowerbehaviourinthisstudy.Despitethis shouldfocusontasks,andalsothatmembersshouldbe
lack of visible success, participants consistently find prepared to shift between the two roles depending on
SBTTextremely positive in published studies.12 13 In the situation, that is, all team members should embrace
these studies, most probably the training curriculum a ‘situational’ or ‘functional’ leadership. Participants
has a high standard and trainers are well-educated, wereexplicitlyinformedofthebehaviouraltargets,and
resultinginpositiveparticipantreactions.1213 received diagnostic feedback for both their role as
Improved self-efficacy regarding medical manage- leader and as follower. As such, the A-TEAM pro-
ment, clinical performance and teamwork in response gramme appears to be successful in training a shared
to simulation-based training has also been shown by leadership,assuggestedbyPearceetal.43
others.38–40 For instance, a crisis resource manage-
ment course with high-fidelity simulation improved
Limitations
self-efficacy in crisis management for emergency
In our training, medical management and clinical per-
medicine residents,12 and final year medical students
formance are discussed in balance with teamwork
after simulation-based teaching reported an increase
behaviours, whereas other types of SBTT emphasise
in self-efficacy.41 However, in the literature, we have
teamwork andteam processesovertask work.7
thus far not found any data on mental strain and con-
Another limitation is the study population of
centration in associationwith SBTT.
In this study, we used elements of ‘leader beha- medical students in that they were all young and clin-
viours’ and ‘follower behaviours’, respectively, for the ically inexperienced. The results regarding individual
behaviour category ‘Take a member role’ in the experiences might not be generalisable to older, more
experienced professionals who may be harder to
A-TEAM programme in order to identify leaders and
motivate.
followers during teamwork in the scenarios.27
Although the literature on teamwork and leadership is
vast, authors seldom declare precisely how leaders are Interpretation
identified, restricting opportunities to compare our The observed increase in self-efficacy was a positive
findings with other authors. That participants in the outcome of SBTT after three scenarios. Although
role of leader communicated to a greater extent than behaviour and clinical performance showed only
in the role of follower was no surprise; the leader minor changes during the short training period, the
directs team and task work, asks for information, increased self-efficacy suggests that the participants’
MeurlingL,etal.BMJQualSaf2013;22:459–467.doi:10.1136/bmjqs-2012-000949 465
Original research
belief in their personal capability of participating in behaviours are different for the roles of leader and
teamwork, and their motivation and commitment to follower. Consequently, the targets for training and
engage in further training, increased.14 As such, the learning outcomes are different. The design of train-
three scenarios enabled further learning in future ses- ing curricula and scenario training should focus on
sions with repetitive practice and iterative scenarios. both roles in order to foster the growth of all aspects
Concentration was stable during training, helping of teamwork competence, and conceivably improve
participants to focus on targets for training. In this patient care.
study, we were not able to tie concentration to learn-
Acknowledgements Thisstudywasfullysupportedbyresearch
ing outcomes, such as clinical skills and behaviour.
grantsfromtheKarolinskaInstitutet,theStockholmCounty
Future studies could analyse the association between CouncilandtheMarianneandMarcusWallenbergFoundation.
concentration, clinical skills and behaviour. WeacknowledgetheskilledstatisticalassistanceofElisabeth
Berg,BSc,DepartmentofLearning,Informatics,Management
Mental strain was also stable, and moderate to
andEthics(LIME),KarolinskaInstitutet.
strong, during the training period. Ifmental strain had
Contributors LM:contributiontostudyconceptionanddesign,
been higher, it might have hindered learning and team acquisitionofdata,analysisandinterpretationofdata,drafting
performance. ofmanuscript,criticalrevisionandfinalapprovaloftheversion
tobepublished.C-JW:contributiontostudyconceptionand
In the role of leader, participants experienced
design,analysisandinterpretationofdata,draftingof
higher levels of concentration and mental strain than manuscript,criticalrevisionandfinalapprovaloftheversionto
in the role of follower. This difference in mental bepublished.LH:contributiontostudyconceptionanddesign,
acquisitionofdata,analysisandinterpretationofdata,drafting
strain suggests that the acquisition of leader beha-
ofmanuscript,criticalrevisionandfinalapprovaloftheversion
viours, and/or leading the team, was more demanding tobepublished.LF-T:contributiontostudyconceptionand
than the acquisition of follower behaviours and/or fol- design,analysisandinterpretationofdata,draftingof
manuscript,criticalrevisionandfinalapprovaloftheversionto
lowing in a team. A balanced combination of these
bepublished.
higher demands and the higher levels of concentration
Competinginterests None.
might have been rewarding.33
Ethicsapproval RegionalaetikprövningsnämndeninStockholm,
Sweden.
Implicationsandfutureresearch
Provenanceandpeerreview Notcommissioned;externally
Even though individual experiences are not included peerreviewed.
in the behavioural targets for SBTT, trainers and
Datasharingstatement Datasetavailablefromthe
researchers should recognise and acknowledge these [email protected].
reactions during training and teamwork. Participantsconsentwasnotobtained,butthepresenteddata
areanonymisedandriskofidentificationislow.
If team effectiveness results from shared leadership,
OpenAccess ThisisanOpenAccessarticledistributedin
as suggested by recent research, then team members
accordancewiththeCreativeCommonsAttributionNon
must be made aware of their individual accountability Commercial(CCBY-NC3.0)license,whichpermitsothersto
for leadership and followership as early as during distribute,remix,adapt,builduponthisworknon-
commercially,andlicensetheirderivativeworksondifferent
training.Itispossiblethatsharedleadershipwillflour-
terms,providedtheoriginalworkisproperlycitedandtheuse
ish when individual experiences and affective factors isnon-commercial.See:http://creativecommons.org/licenses/by-
are recognised andacknowledged duringtraining. nc/3.0/
Furtherresearchisneededinordertoshedmorelight
ontheparticipants’individualexperiencesofteamwork
training, not least in the two roles of leader and fol-
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