Introduction :
Simulcast Journal Club is a monthly series heavily inspired by the ALiEM MEdIC Series. It aims to encourage simulation educators to explore and learn from publications on Healthcare Simulation Education. Each month we publish a case and link a paper with associated questions for discussion. We moderate and summarise the discussion at the end of the month, including exploring the opinions of experts from the field.
Title : “Would you like fries with that?”
The Case :
David ate guiltily in the dark of the McDonald’s car park. The smell of salt, sugar and carbs wafted through his car, and the tension in his shoulders began to release as the raging hunger of a long evening shift without a meal break drifted away. No matter how much he swore to eat healthy, by midnight his frontal lobe was too drained to avoid that drive thru.
“Besides” he thought, he had just realised something interesting.
“McDonalds drive thru attendants are much better at Closed Loop Communication than health care professionals.”
He replayed the conversation in his head again, he had ordered the meal, she had checked what he’d ordered, there was a visual display of his order on the drive thru screen, he’d confirmed his order and she’d told him it would be available soon. It was textbook perfect. Call out. Check back. Confirmation. Completion.
“How do they do it so well?” he thought.
Maybe people get angrier when pickles turn up on their double cheeseburger than when we give their grandma the wrong drug? The world is a strange place when we can’t do something so simple when it’s critical, but we do it so well when the outcomes are meaningless.
“This demands more research.” he thought as he turned his car keys and backed out the car park.
“I’d better come back tomorrow.”
The Article :
Härgestam M, Lindkvist M, Brulin C, et al
BMJ Open 2013;3:e003525. doi: 10.1136/bmjopen-2013-003525
Discussion :
The principles of Closed Loop Communication are frequently taught on Simulation based educational courses. Despite it being a frequently echoed important CRM principal, take up in true crisis situations appears anecdotally variable.
This open access BMJ article from 2013 provides a fascinating look at the uptake of Closed Loop Communication in the Simulation environment, and whether previous involvement in CRM/Trauma courses increases the “Relative Risk” of using Closed Loops.
What are your thoughts on the article and its look at how sim teams communicate? How do we truly get our health care teams closing the loop? What strategies have you found useful in your practice?
References :
Härgestam M, Lindkvist M, Brulin C, et al
BMJ Open 2013;3:e003525. doi: 10.1136/bmjopen-2013-003525
Great topic. I’d never thought of McD’s as being so great at Closed Loop Communication – what an astute observation!
Some interesting observations in the article – I think what stood out most to me was the influence of culture. I wonder if the culture of trauma teams, surgeons leading the trauma team and a historical ‘egalitarian’ approach has facilitated this culture of not closing the loop/speaking up and so on? I have found in my own clinical practice that the more I understand how vital ‘closing the loop’ is. As a leader, more and more I value the benefits of my team closing the loop – it saves me time, we are all up to date and there are better outcomes. As for strategies? For me it has become about being a combination of disciplined and present. Discipline so that I actively practice my communication skills and present so that I focused on the singular task and aware of when I am/am not meeting the benchmark.
Simulation provides us with a unique opportunity to cultivate these skills, deliberately practice and focus on non-technical skills – in my mind they are the ones that can require a more conscious effort to succeed at.
Its not the only place that McDonalds gives us something to learn from in communication training
“Thanks for waiting, now what can I get you” is classic customer service and conflict de-escalation.
Not that I have ever sat at a McDs car park at 1 am. Ever.
So to the study, or Poison regression with my chips.
It was this statement that struck me:
“In this study, it was having a Scandinavian background, not one’s gender or years in the profession that determined a significant increase in the team members’ use of CLC. In this study, all leaders in the trauma teams spoke Swedish fluently, some leaders with an accent, which otherwise would have caused difficulties for the team members. In general, language is an important factor for gaining and keeping power in conversation,23 and a focus of research in the contexts of doctor–patient communication.22 Communication is complex and simple models might not solve the multifaceted problems faced by interdisciplinary teams. Empirical studies of interdisciplinary teams are needed in order to further study the factors influencing communication”.
This partly struck me as my College (ACEM) are currently exploring some of the factors that might link ethnicity with exam performance in an OSCE format including team leading where communication is a specific domain, and callout and closed loop communication is one of a number of aspects being assessed (although this issue has far greater emotion and angst than I have represented). It is interesting to note that in the study it didn’t seem to be rectified despite training, and these are senior consultant doctors.
But the other part, and Jessica has alluded to this, is that it is the culture of the whole team becomes important which means, in turn, that the “followers” are just as important in facilitating and demanding the quality of communication and setting or accepting the expectations.
I wonder how many partial loops got closed:
Give 1 mg adrenaline
1 mg adrenaline given.
In which case the polite leader would say “thanks” and score the next part. Its often that politeness in a resuscitations has great effects not just on calm but also on closure of communication loops.
I will leave you with this clip which I shamelessly ripped off the internet which demonstrates the use of closed loop rather nicely, although the tone does end a little authoritarian.
https://videopress.com/v/0SfSZMzL
Of course, if this was Ben driving home (dangerously sleep and food deprived from nightshift) the final impact would have been obscured by a shower of fries as his greasy fingers slipped on the wheel. Ben and team, thanks again for your efforts in finding us great articles, and look forward to the comments of Sandra, and others.
I realise I’m super-sizing the risk of bias, but I can anecdotally call-out an almost daily difficulty communicating with team members whose first language is different from mine in my clinical environment. It makes teamwork very difficult in a crisis, but I think, more importantly, it contributes to a complete breakdown in team dynamics with a ‘them and us’ culture and frequently adversarial relations.
There, I said it and I’m not proud. But it does emphasize just how critical formalized communication protocols should be in our hospital.
I enjoyed the Methods employed; recording and coding the simulations post-hoc to increase accuracy. I’m sure this implies one of the ‘validities’ that should be sort in sim research but I have not managed to nail down a decent understanding of ‘validity concepts’ yet. (Go-on then @sim_podcast team… there’s a challenge) But I fear this sort of equipment, time and labour intensive approach would be beyond my setting.
I can’t comment on the fishiness of their regression analysis, but the findings that team leaders used CO more than followers, or that seniority/experience increased the RR of CO is I suppose unsurprising. I’m not too sure how to interpret the RR for CLC other than to say the overall use of CLC seems low.
The problem that jumps out at me from this article is that, despite most the team members having received significant amounts of training that included CO and CLC techniques, they weren’t used. Which yet again illustrates the conundrum that education and training, or even knowledge of best-practice, doesn’t always translate into practice.
As an educator, I so want to believe that teaching people the right way to do things will mean just that; a change in practice towards the gold-standard, but it doesn’t.
So my question to the team is: What are your experiences of the influence of sim on changing the culture of practice in your institution? Perhaps you have some references to translational work? Where we have a broken team dynamic, will we be able to use sim to re-create that feeling of team-ness?
Looking forward to hearing some thoughts. Thanks again Ben and the team. And Ben, I didn’t even know you were nervous on the podcast, honest, really, cross-my-heart.
Just to check was this video taped or audio taped? Was there the possibility that non verbal cues such as eye contact and nodding which might constitute the final closure could be missed? Not saying that this is necessarily the safest or best thing to do but it certainly happens. Same with a quiet “ok” lost amongst noise by everyone except speaker and target but might be more obvious if you are watching live from within a busy room.
Could use of body language and hands be cultural? My Italian mates would say
… flurry of hand movements..
Ian
Thanks so much for your comments Jessica, Ian and Rowan. I’m enjoying the fast food puns as much as the article discussion :p
I think the take home messages and thoughts that struck me when I read this article were :
1. Holy shit, we’re so bad at this. It’s really important. Oh god, how are we so bad at this???
2. Egalatarian leadership style increases chance of other people using closed loops (modestly, but I haven’t seen hard evidence for it before). For me, some evidence that an authoritarian approach to a resus is inferior to collaborative styles. Useful when teaching CRM.
3. Watching a video about CLC or doing a single course doesn’t increase your use of CLC, but doing several courses did improve it slightly. Maybe people can change, but it takes a lot of work and time to change the way you communicate?
4. Cultural differences in a resus can have an effect on interactions within that team. (I get that this is kind of stating the obvious, but I found value in this article making the implicit concept explicit.)
Overall for me, my response was similar to Rowan’s :
– Oh god, just teaching people this stuff doesn’t seem to work that great. Is it all for nothing?
In response to your question regarding anecdotal evidence Rowan, I would have to say the Tertiary Paediatric ED I worked for seemed to have markedly better resus communication than other units I have worked in. I think that the frequent participation in weekly sims as well as monthly CRM and trauma courses hosted by the unit lead to a long term, impactful, cultural change. In regards to how hard it is to change behaviours, I remember Jenny Rudolph saying on a course that we are socially conditioned to conceal what we are thinking. Transparency of thinking is utterly counter intuitive. I think that is a major part of why it is so hard to alter our communication and teamwork styles -> they are inherently tied with our upbringing and herd behaviours.
Ian, from what I can read the video capture of the sims was audio and visual, but I noted with interest your point regarding a lack of comment on non verbal communication. Particularly as the data was transcribed. I’d now love to see an Italian Trauma SIM with the sound off.
For myself I use this article to justify to learners :
– This stuff doesn’t come easy, it is not instinctive, and (as Jessica alluded to) you need to practice it every day, when you don’t need it, so that you use it all the time, not just in a crisis.
– If you set a tone in your resus that closed loop communication is expected, then the team culture will be more likely to speak up for safety, to fact check, and to contribute to a successful outcome, as you have subconsciously decreased the risk of clarifying miscommunication.
I do love that video clip Ian.
Yes agree, loving the puns 🙂
I’m not quite as convinced about what is a ‘good’ number of closed loop communications. Agree that acknowledgement may have been non-verbal, but maybe also there are come ‘CO’s that maybe don’t need explicit acknowledgment?
Participants may also be cognisant of ‘signal and noise’ issues. I have noticed differences between US and Aust – latter generally quieter resus rooms – maybe we should be doing more CLCs?, but it means that when someone does say something – we hear it.
Also no expert on Poisson regression, but the above issue ie what is a clinically significance difference in number of CLCs – would have a big impact on whether any factors were found to be significantly associated with it.
Rohan – why would i do a podcast on validity when the master himself Jon Sherbino has done one …..https://icenetblog.royalcollege.ca/2016/01/22/keylime-101-validity-ugh-a-better-approach-for-meded/
🙂
But the main issue related to training and communication outcome is not surprising.
Will dig out reference but i remember a nice piece on communication skills training in medical schools and conclusion that “training in communication skills does not necessarily lead to skilled communication”
Communication is a symptom/ outcome of complex human relationships. The ‘skill’ element is only as good as the ability to overcome challenges inherent in the socio-cultural context. Rowan’s honest comments and the findings of the scandinavian factor in the study tend to suggest that.
We can teach SBAR all we like – but handover just isn’t that simple.
Does it mean we stop trying ? 🙂
I don’t think so (obviously)
But i think we stop trying to hammer in ‘recipes’ and explore barriers as much as we give tools. Sim is good for that too.
Thanks again Ben and others – great discussion
Sorry for the delay. (Somehow, I managed to get myself sealed into the walk-in fridge, please bear with me while by brain returns to room temperature 😉
Many excellent points above – it seems to me that the practice of teaching communication drills is not necessarily resulting in communication skills. The work that Steve and I have been doing on High Abstraction simulation aims to get people to think much more about what they are saying (and also to get them to exercise their thinking in ways that are probably unfamiliar and strength-building). I need to get myself organized and get a trial to happen!
Boring things like closed-loop communication are more likely to be lost when the cultural pressures of the normal workday apply than anything else; I’d expect any gains to be short term without a culture that reinforces the habit. When it comes to establishing an unfamiliar competence, I don’t think it’s enough to show a video and then do what you normally do – I think you need exercises that are structured specifically to force people to exercise those unfamiliar muscles.
Related to the #hellomynameis program, I believe first names are really important in team communication. The Methods states that “The participants consisted of personnel from 19 trauma teams involved in regular team training.” However no mention is made of whether first names were familiar in the group, or if name badges or labelled scrubs/vests were worn.
To address a person directly as part of a closed loop is much more effective than a general call out. The study states in the discussion “When there are too many COs being sent out to no one in particular, there is a risk that the commands given will not make themselves heard in the noise, and the task will not lead to action.”.
One area of further research may be testing an adhoc team without name badges/vests and comparing to the outcomes of a well introduced or labelled group.
Thanks for sharing this! Kudos to the researchers for studying resus team communication that I imagine would be difficult to define and study.
I can totally relate to the 1am McDonalds visit after a long late shift!! Although I say no to the fries for health reasons…
For me its difficult to say for sure if the number of CLC events were low, as we have no reference as to what a “good” number of CLC events would be. I’m not convinced that every CO should result in a CLC. For example if the nurse calls out “the patients blood pressure is 70”. The team leader might make eye contact and look at the monitor herself and acknowledge it, but not necessarily repeat back “Yes I note the patients BP is 70”. CLC used to that extreme level would just add to the noise in the resus room. Having said that, 2.8 CLC’s per simulation sounds a bit low.
Also we can’t say that the training has had no effect, as we don’t know how many CLCs would have been there without any training – it may well have been zero! Maybe the few CLC events introduced as part of the training made all the difference in avoiding an error. So I wouldn’t rule out the fact that the training may have had some effect!
There were a lot of tables breaking down the number of CLC events based on the participants characteristics. Some of this data seemed a bit pointless. For example the team leader will clearly initiate more CO and CLC events that the operating theatre nurse – so this seemed like data that was not particularly useful.
As Ian has eluded to – the cultural differences in communication is noteworthy, and topical, given accusations made by certain individuals about the ACEM fellowship exam. Would be certainly an interesting area to see more studies in!
I think that changing culture in relation to issues like communication is very difficult because it is hard to measure. Often organisations tend to measure things that are easy to measure, and not necessarily the most important. For example it would be easy to measure “time to analgesia”, or other time based targets and use repeated measures of this data to encourage cultural change, but its much harder to measure things like “good communication” or “empathy”. The most obvious example in the world of emergency medicine would be compliance with the NEAT target, and equating this with quality of care.
I think the one thing I would take away from this study to my own practice was that the “egalitarian” leadership style potentially encouraged more CLC than the “authoritarian” style. So I will try make more of an effort as a team leader to empower the team to verbalise their concerns/ ideas more.
Once again – thanks for sharing the article, and thanks everyone for the great discussion!!
Thanks for joining us Simon and Suneth!
I agree that first names are powerful in a resus Simon, but I have to confess I’m terrible at remembering names at the best of times and in a resus I’m even worse. I think clear name badges sound like a great systems based solution to that. Most name badges are small and combined with my short sightedness, don’t lend to great readability during a resus. Maybe names on the back and front of scrubs like a team jersey? :p
Suneth great to hear from you, I agree with your thoughts about organisations measuring easy things to measure rather than the things that are more important but qualitative. I think this study is a good attempt, but so far our jclubbers seem to want more depth of data to play with.
” Maybe names on the back and front of scrubs like a team jersey?”
If doctors and nurses could be persuaded to wear them, I think this would actually be quite excellent. It’s a pretty big ‘if’ though.
Yeah I think there would be some resistance :p Kinda fun though!
Are you guys in the first world not using Google-glass augmented reality glasses with facial recognition and heads-up name displays yet? I thought everyone was?
In the meantime I’ll just stick to remembering names, so thanks again Bon Symen for all your work on the JC.
Shush country mouse :p