closed loop communication and shared mental model (Riley
et al. 2008). The scenarios included typical distractions
such as an overly inquisitive or rude significant other, a
language barrier, talkative mother, lack of a prenatal
record and other factors that interrupt team flow so that
the simulation team would be stressed by both the
clinical and social aspects of the care. Each simulation
started with a briefing on labour and delivery discussing
the simulation process, limitations and the importance
of performing as one would normally perform during
actual clinical care. Participants were told that the
observers were looking for teamwork and communication
skills, not for technical skills.
In situ simulations started with the nurses first
encounter with the patient, often walking into the room
with the patient. Simulations had a typical framework
of one nurse and the patient, two nurses and the patient,
the addition of an obstetrician, and taking the patient to
the operating room for an emergency caesarean section.
This framework became the stages of our evaluation.
These event sets (Hamman 2004) contained specific
triggers (sudden clinical changes) and distractors
(elements designed to divert the teams attention) that
created stress for team members (Miller et al. 2008).
In previous research, we identified six distinct stages
with unique primary tasks. During each change in a
stage or task or team, a significant leadership event
occurred; leadership was established, maintained or
transferred (Riley et al. 2008). The performance of
these teams throughout the critical event was sporadic
and uneven. Highly-reliable team performance regarding
situational awareness, SBAR-R, closed-loop communication
and shared mental model was not
consistently observed. Previous research findings indicate
that four main team human factor and communication
failures account for the bulk of the breaches in
defensive barriers during critical events: loss of
situational awareness by the team leader, inadequate
SBAR-R (a handoff technique), lack of closed-loop
communication and failure to establish a shared mental
model (Davis et al. 2008, Miller et al. 2008). Table 1
lists these four communication