From Aviation To Healthcare: How Crew Resource Management Translates To The Medical Domain

Even though commercial aviation dates back only about 100 years in history, today, an aircraft is one of the safest places to be, unlike hospitals, which are considered an environment where errors and threats are so imminent that the World Health Organisation issued a “Curriculum for Patient Safety.”

The aviation community managed to reduce fatal accidents since the 1980s by acknowledging that technical failures are not the main threat to complex and potentially hazardous systems. The actual threats are human factors, or a combination of technical, social, and human factors.

Cockpit and cabin crew, therefore, attend “Crew resource management” (CRM) training to make them aware of human errors and respective countermeasures with three lines of defence: (1) avoidance of error, (2) trapping incipient errors before they are committed, and (3) mitigating the consequences of those errors which occur and are not mitigated.

Even if first efforts to transfer such CRM training from aviation to healthcare teams set in soon after CRM evolved in aviation more than 30 years ago, only in recent years has there been a strong increase in the number of healthcare team- and CRM-training publications.

What is “inside the box” of CRM training?

While the medical domains’ attention to the effects and benefits of CRM training is rising, the content of such training has not been clearly defined or consented to in the form of a syllabus yet. Only a few standardized curricula are available for human factor training in healthcare settings. Most training labeled as “CRM training” are human factor team training that are self-constructed interventions for the context of individual hospitals or specific hospital units.

While increasing attention on human factors in a healthcare context can only be welcomed, a lack of standards or common definitions presents a risk: what exactly is it that healthcare teams are taught under the label of “CRM training”? Will two healthcare teams enrolled in different CRM training receive the same input on knowledge, skills, and practice?

This question was approached by a systematic review of studies reporting CRM training interventions in healthcare. A database search identified 61 studies that met the inclusion criteria for the review. The analysis of those studies unveiled frequent topics in the training content and also some important aspects to pay attention to for future research in the field.

Figure 1: Increase of crew resource management (CRM) training publications listed in PubMed over the years. The graph shows the proportion of CRM publications per million total records in PubMed for a 3-year span. Figure republished with permission from BMJ Open from https://www.doi.org/10.1136/bmjopen-2018-025247.

Who receives CRM training in healthcare?

More than 80% of the studies report CRM training that was delivered to professionals who work as teams in operating rooms, emergency medicine, ICUs, anesthesia, or obstetrics. These teams often have similar characteristics like frequent changing team constellations, functional role structure, high skill differentiation, but also high authority differentiation and interdependence. First and foremost, these healthcare teams are confronted with critical situations on a regular basis and, therefore, are likely to acknowledge the benefits of CRM, which might explain why these kinds of teams are dominantly represented among the study populations. However, it is reasonable to assume that CRM would benefit other teams engaged in patient care as well.

What topics are taught as CRM?

When it comes to training content, about half of the studies did not provide adequate detail or keywords that would allow the CRM intervention to be replicated. Terms or concepts were named to describe CRM interventions but without giving a definition of the term or concept. For instance, in 48 articles, “communication” was part of the training, but only 13 articles explained what it exactly meant to train participants in communication. Similarly, 24 articles had “decision-making” in their training schedule, but only three described how this was implemented to a reproducible level of detail.

How is CRM training provided?

The efficiency of CRM training concepts and related didactic concepts was investigated in only a few studies. The overall question of most of the publications was, “Does what we do work at all?” but they didn’t ask, “Are we doing it in the best possible way?” This is somewhat also reflected by the recruiting and preparation of faculty for CRM training in the healthcare domain. It could be expected that the selection of trainers would reflect various professional backgrounds to cover all scientific areas. Surprisingly, more than 50% of the studies did not include the qualification or professional background of the training faculty. They also did not describe how their instructors were prepared for the challenges of interactive training formats in a small group of participants with close interactions.

The review also provides a direction for future research. It appears that only a few studies considered non-educational factors that are beneficial to CRM training but beyond the scope of a training intervention in a narrow sense.

Some instances were a study that involved executives and managers in the design of the CRM intervention to make them active stakeholders in the transformation of organizational culture, during CRM training that was followed by a 6-month phase of coaching and mentoring to implement the learnings in daily routines. Such invention concepts did not stop after delivering training but provided an organizational change process to ensure a transfer into practice. It seems plausible that training alone will not provide a noticeable change in behavior. More attention is needed to understand and address the prerequisites and necessary measures at the organizational level to make CRM fully woven into hospitals’ culture.

A diversity of concepts and methods to make healthcare safer

After all, there is no easy answer to the question, “What is CRM in healthcare?” CRM training is composed of diverse concepts and methods of communication and collaboration. Training formats and evaluation approaches varied strongly. CRM, in its current state in a healthcare context, appears to not be a clearly-defined training intervention, but rather an umbrella term under which human factors and safety training are provided.

Figure 6: What topics are taught in healthcare CRM training? Figure republished with permission from BMJ Open from https://www.doi.org/10.1136/bmjopen-2018-025247.

Actually, “CRM” is loaded with a great plurality of skill areas, topics, multiple settings for training, and evaluation procedures. It would only be beneficial for healthcare CRM application and research to establish a definition for CRM in healthcare together with a glossary to bring structures into concepts, terms, and techniques.

Increasing numbers of researchers and practitioners in healthcare seem to agree upon the need to improve teamwork in order to strengthen patient safety. Many of those obviously acknowledge CRM as a suitable method; participants of the training also perceive it as beneficial, and positive effects at the organizational level have been found. But the systematic literature review also demonstrates that CRM needs a lot more than merely training to become operative: A single training alone stands little chance of generating a lasting change of behavior and noticeable effects; implementing CRM requires organizational support and change management efforts for lasting effects.

There is an ongoing process of evolution of safety management in healthcare that involves human factors in the design and operations of institutions. We analyzed a snapshot of the current state of research in CRM training for healthcare professionals that appears still fuzzy but promising: hospitals are getting safer.