title: Speaking up is related to better team performance in simulated anesthesia inductions: an observational study.
abstract: BACKGROUND
  Our goal in this study was to test the relationship between speaking up--i.e., questioning, correcting, or clarifying a current procedure--and technical team performance in anesthesia. Hypothesis 1: team members' higher levels of speaking up are related to higher levels of technical team performance. Hypothesis 2: team members will react to speaking up by either clarifying their procedure or initiating a procedural change. Hypothesis 3: higher levels of speaking up during an earlier phase of teamwork will be related to higher levels of speaking up during a later phase.
  
  
  METHODS
  This prospective observational study involved 2-person ad hoc anesthesia teams performing simulated inductions of general anesthesia with minor nonroutine events (e.g., bradycardia) in a large teaching hospital. Subjects were registered anesthesia nurses and residents. Each team consisted of 1 nurse and 1 resident. Synchronized video and vital parameter recordings were obtained. Two trained observers blinded to the hypotheses coded speaking up and further team communication and coordination behavior on the basis of 12 distinct categories. All teamwork measures were quantified as percentage of total time spent on the respective teamwork category. Two experienced staff anesthesiologists blinded to the hypotheses evaluated technical team performance using a Delphi-validated rating checklist. Hypotheses 1 and 3 were tested using linear regression with residents' and nurses' levels of speaking up as 2 separate predictor variables. Hypothesis 2 was analyzed using lag sequential analysis, resulting in Z values representing the extent to which the observed value for a conditional transition significantly differs from its unconditional value.
  
  
  RESULTS
  Thirty-one nurses and 31 residents participated. Technical team performance could be predicted by the level of speaking up from nurses (R(2) = 0.18, P = 0.017) but not from residents (R(2) = 0.19, P = 0.053); this result supports Hypothesis 1 for nurses. Supporting Hypothesis 2, residents reacted to speaking up with clarifying the procedure by providing information (Z = 18.08, P < 0.001), initiating procedural change by giving instructions (Z = 4.74, P < 0.001) and team member monitoring (Z = 3, P = 0.0013). Likewise, nurses reacted with clarifying the procedure by providing or evaluating information (Z = 16.09, P < 0.001; Z = 3.72, P < 0.001) and initiating procedural change by providing assistance (Z = 0.57, P < 0.001). Indicating a trend for Hypothesis 3, nurses' level of speaking up before intubation predicted their level of speaking up during intubation (R(2) = 0.15, P = 0.034), although this did not reach the Bonferroni-corrected significance level of P = 0.025. No respective relationship was found for residents (R(2) = 0.15, P = 0.096).
  
  
  CONCLUSIONS
  This study provides empirical evidence and shows mechanisms for the positive relationship between speaking-up behavior and technical team performance.
authors.affiliation: ETH Zurich, CH-8032 Zurich, Switzerland. mkolbe@ethz.ch
authors.forename: Michaela
authors.initials: M
authors.lastname: Kolbe
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Burtscher
authors.forename: Johannes
authors.initials: J
authors.lastname: Wacker
authors.forename: Bastian
authors.initials: B
authors.lastname: Grande
authors.forename: Renata
authors.initials: R
authors.lastname: Nohynkova
authors.forename: Tanja
authors.initials: T
authors.lastname: Manser
authors.forename: Donat R
authors.initials: DR
authors.lastname: Spahn
authors.forename: Gudela
authors.initials: G
authors.lastname: Grote
mesh_terms: D000758:Anesthesia / Q000379:methods / Q000592:standards*; D002983:Clinical Competence / Q000592:standards*; D003198:Computer Simulation / Q000592:standards*; D003299:Cooperative Behavior; D006801:Humans; D007857:Leadership; D010348:Patient Care Team / Q000592:standards*; D011446:Prospective Studies