Crew Training-Enhancing the Voice of Nursing in Womens Health

Purpose & Rationale  
In 2004, a JCAHO review found that the majority of perinatal death and injury cases were related to problems with organizational culture, teamwork failures and communication breakdowns among caregivers and recommended that team training be conducted in perinatal areas. The Crew Training program is a major performance improvement initiative for Women’s Health Services (WHS) and supports and exemplifies the Magnet Forces of Nursing Leadership, Quality Improvement and Interdisciplinary Relationships.

Synthesis/Review of the Literature
Risk Management Foundation (RMF) developed Crew Training specifically for obstetrical services. This innovative program uses Crew Resources Management (CRM) work developed by the American Institute for Research and the Department of Defense. CRM concepts include: asking and offering relevant information, communicating proposed action, advocating, and providing for conflict resolution. These concepts have been successfully transferred to healthcare and have shown improvements in staff attitudes, patient outcomes, communication skills, decreased costs and improved patient satisfaction.

Methods
Using a Train the Trainer model, 5 RN/MD teams participated in a three-day program on building and mentoring effective OB teams.  In 2006, these 5 teams trained over 400 nurses, obstetricians, anesthesiologists, residents and ancillary staff in WHS using the 4-hour TPP training program.   To evaluate improvements, the National Perinatal Information Center gathered benchmark data on clinical outcomes, patient safety, and patient/staff satisfaction.  Comparative data on adverse outcomes developed by RMF will be used to evaluate progress quarterly with other Crew hospitals. In addition, data on process and nurse/physician perceptions have been collected by WHS for interim evaluation.  

Results
To date, more than 500 staff have completed Crew training and the Labor & Delivery unit has implemented the CRM concepts into practice.  A coaching model is assisting in supporting the necessary culture change, communication skills and conflict resolution strategies learned in the program.  Many system changes have already been made including: the development of a new L&D Team structure with an obstetrician on the Coordinating Team 24/7, a new Triage/OR nursing role, a contingency team for responding to unit emergencies, the integration of Crew communication strategies such as team meetings, debriefings and SBAR.  Crew training has provided support for the Magnet Forces of Nursing Leadership, Quality Improvement and Interdisciplinary Relationships.  The nursing staff has an enhanced voice in patient care and planning.  It has given nurses a new forum for patient advocacy and quality improvement and they are experiencing a greater respect and value for their input from physician colleagues and peers.  Interdisciplinary relationships continue to improve as practice and behaviors shift to integrate the Crew concepts. 

Discussion/Application to Practice
Although these changes are primarily qualitative at present, our fervent belief is that over time they will demonstrate quantitative improvements in patient safety and outcomes, staff attitudes, interdisciplinary communication, hospital costs and improved patient satisfaction.  Crew’s support of the Magnet Forces is presently demonstrated in the L&D nurses’ experience of greater respect and value.  As Crew concepts continue to be integrated throughout WHS, we hope that practice, communication and overall patient safety will continue to improve.