WHO’S ON FIRST?

In our article ‘Comparative Issues in Aviation and Surgical CRM: (1) Are we too solution-focussed?’, we suggest that the assumptions that underlie aviation-based crew resource management (CRM) are unlikely to be applicable to health care. Our reason for this is that whereas in aviation, the context and dynamics of team performance are predictable and have been shown through significant research over the past three decades, the same is not true for health care and close analogies are unlikely to be found. One key aspect of CRM training in aviation is the concept of enquiry/advocacy/assertion that promotes a learning climate. Effective evidence-based CRM training in this area requires a detailed understanding of the communication and authority relationships that currently exist in the environment in which training is to take place. Our view is that in health care, there is a widely held assumption that the nature and dynamics of these relationships are understood and agreed upon. Judgement is passed regularly on competence of practitioner responsibility and communication by organizations with a regulatory function or perceived regulatory function, for example, a Health Practitioners Disciplinary Tribunal or the individual professional registration bodies. In these settings ‘expert’ practitioners are often asked to comment on whether an individual doctor provided a patient with services to an appropriate standard. In response, these experts often refer to ‘standard practice’.1 Standard practice is unequivocal in aviation. For example, in terms of leadership authority and responsibility for decisionmaking, it is vested in each individual crewmember’s role and specified in legislation. Unlike aviation, we suggest that the significance of hierarchical system in health care is ambiguous and often unknown. A summer student of ours recently conducted a pilot study investigating the perceptions of staff with regard to communication and authority relationships in a perioperative setting within a New Zealand tertiary care centre. Potential participants were all members of the adult perioperative teams – surgeons, anaesthetists, surgical and anaesthetic registrars and surgical house surgeons, and nurses working in surgical wards, high dependency units, recovery rooms and theatres. Participants were required to have regularly worked at least 20 h/week and have worked for at least 6 weeks in this setting to participate. There were 204 potential participants in total. The study used a scenario-based questionnaire requiring openended responses or choice of fixed alternatives. The first scenario was based on an event published in the New Zealand Medical Journal.2 The second scenario captured a situation that had been experienced by several medical practitioners known to the research team. The third scenario was based on a report by the Health and Disability Commissioner.3 Pretesting of the questionnaire was conducted using members of the academic surgical, anaesthetic and nursing departments at the University of Auckland. These respondents were asked to comment on the questionnaires contents, clarity, appearance and potential for ambiguity. Eight-one responses were obtained from 204 potential participants (40%). Responders comprised nine surgeons (including registrars), 15 anaesthetists (including registrars), 10 clinical nurse leaders (including nurse managers, nurse educators and clinical nurse specialists) and 47 staff nurses. Responses obtained from each questionnaire were examined for overlapping concepts and repetitions, and a composite list for each question compiled. No attempt was made by the researchers to resolve response ambiguity, for example, it was unclear whether the ‘surgical team’ comprised doctors and nurses or only doctors (although the researchers impression, in the context of the responses, was that ‘surgical team’ referred to doctors only) and thus was left as a category in its own right. It is not possible for us, in this paper, to provide a comprehensive analysis of the results, so the following is a brief overview of the first (and least complicated) scenario.