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World Journal of Nursing Sciences 5 (3): 104-116, 2019ISSN 2222-1352 © IDOSI Publications, 2019DOI: 10.5829/idosi.wjns.2019.104.116

Corresponding Author: Reem Mabrouk Abd El Rahman, Faculty of Nursing,Damanhour University, El-Beheira, Egypt.

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Effect of Nursing Crew Resource Management Training onTeam Task: Characteristics and Performance

Reem Mabrouk Abd El Rahman and Nevine Hassan Abdelaal

Nursing Administration Department, Faculty of Nursing,Damanhour University, El-Beheira, Egypt

Abstract: Crew resource management is one of an array of tools that organizations can use to manage error andis essential for any health care organizations. Effective nursing teams' characteristics produce greater qualityof care and are integral part of team’s task performance. This study aimed to determine the effect of nursingcrew resources management training on team task characteristics and team task performance, in intensive careunits at Damanhour National Medical Institute. The study was conducted at all critical and intensive care units,at Damanhour National Medical Institute. All staff nurses (n=53) were included in the study. Four tools wereused: Tool (I): is composed of two parts: first part is Demographic data sheet; second part is Crew ResourceManagement (CRM) Questionnaire; tool (II): Team Task Characteristics Instrument; tool (III): Team TaskPerformance Questionnaire; and finally, tool (IV): CRM Knowledge Test. Results showed highly significantdifferences between total crew resource management and its domains; and between total team taskcharacteristics and task significance domain; and between total team task performance and its practices, at pre-,immediately after and after three months from training program implementation (where P 0.01). Moreover, staffnurses' knowledge score related to Crew Resource Management, team task characteristics and team taskperformance, immediately after training program were good (92%). Finally, highly significant positivecorrelations between crew resource management, team task characteristics and team task performance weredetected (where P= .001, .000, .002), respectively. Conclusion: nursing crew resource management training hadpositive effect on team task characteristics and team task performance, in intensive care units at DamanhourNational Medical Institute, at immediately after and after three months from training program implementation;compared to pre-implementation. Moreover, staff nurses' knowledge score was good immediately after trainingprogram implementation; compared to pre-implementation. Recommendations: Conduct organization-wide crewresource management training to create a continuing culture; believe in staff nurses’ abilities and tasks; inspirethe formation of a close-knit cohesive teamwork climate and communications with other departments; and valuethe crew resource management-based approach.

Key words: Crew Resource Management Team Task Characteristics Team Task Performance

INTRODUCTION Organization (WHO) Curriculum for Patient Safety [2].

Over the last few years, health care delivery performance and preventing accidental harm. Forsystems need to exert major reduction in number of healthcare, this means supporting the cognitive andfatalities concerned with errors through identifying, physical work of healthcare professionals and promotingassessing, reducing and dealing with diverse risks high-quality, safe care for patients [3]. ‘Crew resource[1]. Human factors, as a central issue, have been management’ (CRM) trainings were adapted from aviationincreasingly recognized as a source of medical error; for healthcare teams as an instrument to address humanand today, errors are acknowledged as a serious threat factors. CRM is one of an array of tools that organizationsto patient safety, as described in the World Health can use to manage error [4].

The human factors are about improving system

World J. Nursing Sci., 5 (3): 104-116, 2019

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Crew resource management (CRM) encompasses a Nursing teams are important in ensuring positivefocus on managing the limitations of human performance,such as fatigue, high workload and distraction duringcritical tasks are highlighted, along with specificcountermeasures [5]. It is defined as: “a training andperformance improvement intervention used to reducehuman errors in high-risk industries” [6]. Moreover,CRM training was defined as “instructional strategiesdesigned to improve teamwork in the cockpit by applyingwell-tested training tools (e.g., performance measures,exercises, feedback mechanisms) and appropriatetraining methods (e.g., simulators, lectures) targeted atspecific content (i.e., teamwork knowledge, skills andattitudes)” [7].

Today, CRM is an essential part of any trainingdepartment in health care organizations and is a criticalpiece of knowledge that is tailored to the appropriatecontext setting, especially in Intensive Care Units (ICUs)[8]. It focuses on behaviors and strategies that are usedby leaders and subordinates to ensure that effectiveteamwork and communication take place, especially whenoperational safety is in question. It can be supposed aslearning the interpersonal aspects of functioning in ahigh-risk, dynamic environment, optimizing the decision-making process. These skills, when coupled with technicalproficiency, ensure a higher degree of operational safetyand risk mitigation [9]. The use of briefings and checklists,adherence to standard operating procedures, use ofstandardized communication patterns, teamwork and themaintenance of adequate levels of situational awarenessare a challenge in the clinical environments of ICUs [5].Hierarchical cultures, short staffing, increased patientacuity, high task load and rapidly evolving technologycreate threats resulting in incomplete communication, tasksaturation and poor decision making at the bedside [10].

A nursing-focused CRM program at the point of carecan effectively manage these threats. Nurses at thefrontline deliver most of the direct care and spend themost time with hospitalized patients. It is also clear thatnurses play a critical role in patient safety through bothsurveillance and interception of system errors that cancause harm [11]. This program should focus on maindomains, as: team climate, safety climate, interpersonalcommunication and perception of management, whichimprove nurses' attitude toward teamwork, behaviors,patient safety and care efficiency [8]. The application ofCRM in the context and domain of nursing units is vitaland offers the potential for cultural and risk-relatedimprovements similar to those realized in aviation.Therefore, a nursing-focused CRM program is consistentwith the "single discipline teams" approach, which is bothessential and valuable in CRM implementation [8].

patients' health outcomes, as nurses are becoming highlyinterdependent. Effective nursing teams' characteristicsproduce greater quality of care and patient satisfactionwith fewer errors and are considered as a majorcomponent in healthy workplaces [12]. Team taskcharacteristics are operationalized as: task identity, tasksignificance and task interdependence. Team taskcharacteristics are integral part of team’s task performancebecause team task affects team’s direction in terms of itsmotivation and coordination to achieve the team’sgoals and its effectiveness for better performance [13].The effective team task functioning is a significant issuein hospitals for effective work outcomes and health careservices [14].

In nursing teams, team task performance is mirroredthrough the complete understanding of clinicalinformation of the patients. High understanding oftechnical and clinical knowledge will impact how the teamresponds during critical incidents [15]. With enoughknowledge on assigned tasks, high performance teamswill have less work duplication and are able to detectresources efficiently [16]. In definition, a goodmanagement of task will reflect a high pursuit of taskperformance among nursing teams. McShane and VonGlinow [17] characterized it as the level a team andindividual team members meet goals, while sustaining theteam over time.

The team task performance involves a proposed setof best practices that staff nurses should perform andinclude: purpose and goals; team member role; teamprocess; team relationship; intergroup relation; andproblem solving. The team task performance isappropriate to measure the efficiency of staff nurse,depending on the nature of a job [18]. Team taskperformance is markedly improved by CRM and team taskcharacteristics; therefore, CRM training is becomingmandatory for health care professionals in Europe andUSA [19].

Significance of the Study: Nowadays, Health care is aninterdisciplinary system and reliant on teamwork toprovide the care to individuals [20]. Successful teamingdirectly relates to the efficacy of the hospital. I.C.Uenvironment is a place characterized by mistakes due tothe multidisciplinary teams, critical time to care for allpatients. Patients in I.C.U. require more testing,monitoring and different kinds of treatment andmedications administration than other departments inhospital and errors have greater impact due to biggerpatients’ vulnerability [21]. Safe work in I.C.U relies on


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team task performance, as much as on individual expertise. Institutes; and is considered the main teachingSafety climate is considered one of the main contributing hospital at El-Beheira governorate equipped with 336factors of quality of care [22]. Crew resource management beds. The facility offers a full range of servicesis considered as a tool or way for culture change in I.C.U., including acute inpatient care, intensive care units andif it is supported by head nurses to promote team task partial hospitalization services; as well as paramedicalcharacteristics, which have an impact on team task services.performance and operation efficiency.

Hospitals are beginning to understand the value of Sample: All staff nurses, who were working in theeffective teaming and as a result, are now providing team previously mentioned settings and had at least one yeartraining to staff [23]. In this concern, Neily et al. [24] of working experience, were included. (N = 53).analyzed that health care team training program resultedin significant reduction in surgical mortality rates. In Tools of the Study: The data was collected throughnursing teams, team task performance is reflected through self-administered questionnaire encompassing fourthe full understanding of patients' clinical information. tools:High understanding of clinical and technical knowledgewill influence how the team reacts during critical incidents Tool (I): Is Composed of Two Parts. The First part Is a[15]. With sufficient knowledge on assigned tasks, highperformance teams will have less duplication of work andare able to locate resources efficiently [16]. In definition,a good management of task will reflect a high pursuit oftask performance among nursing teams. Hence, this Studywill give more insight on further knowledge for headnurses on how nursing crew resource managementprogram is related on team task characteristics andnursing team performance that are beneficial for team andworking unit outcomes.

The Aim of the Study: The aim of this study was todetermine the effect of nursing crew resourcesmanagement training on team task characteristics andteam task performance, in intensive care units atDamanhour National Medical Institute.

Research HypothesisH1: There is an effect of nursing crew resource

management training on team task characteristics andteam task performance, in intensive care units atDamanhour National Medical Institute, post training“significant improvement”.

MATERIAL AND METHODS

Research Design: A quasi-experimental, interventional,pre-test/post-test study was utilized.

Setting: The study was conducted at DamanhourNational Medical Institute; at intensive care units (N=3),namely: general Intensive Care Unit (ICU); coronary careunit; and neurosurgery ICU. The institute is affiliated tothe General Organization for Teaching Hospital and

Demographic characteristics Questionnaire: Concerningage, educational qualification, working place, experiencein nursing (years), unit experience (years) and maritalstatus. The second part is the Crew ResourceManagement (CRM) Questionnaire, developed byresearchers after thorough review of related literature[1, 5-7, 20, 22] which was used to measure staff nurses'perception of nursing CRM. It has 32 items, grouped intofour domains, namely: (1) team climate (8-item); (2) safetyclimate (8-item); (3) interpersonal communication (8-item);and finally, (4) perception of management (8-item).Responses were measured on a 5-point Likert scaleranging from 1 “Strongly disagree” to 5 “Strongly agree”.The scale has high internal consistency ( =.924). ScoringSystem: The scale is scored by summing the items, withgreater effectiveness indicated by higher scores. The totalscores are the average of the item ratings and can rangefrom 32-160.

Tool (II): Team Task Characteristics Instrument: It wasdeveloped by Zawawi and Nasurdin [13], to measureperceived team task characteristics from staff nurses'perspectives. It contains 9 items that are grouped intothree domains (3-item/each): task identity; tasksignificance; and task interdependence. Responses aremeasured on a 7-point Likert rating scale ranging from1“strongly disagree” to 7 “strongly agree”. The scale hadhigh internal consistency ( =.796). Scoring System:The scores for each domain are calculated by obtainingthe mean score for all items on each one. The total scoresare the average of the item ratings and can range from9-63. The higher overall and domains scores areinterpreted as staff nurses' perceptions of effective teamtask characteristics.


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Tool (III): Team Task Performance Questionnaire: The tools used in this study had high reliability, byIt was developed by researchers after thorough review ofrelated literature [13, 16, 18, 23, 25-28], which is used tomeasure effectiveness of team members performance.It has 42 items, grouped into six set of practices, namely:(1) Purpose & goals (7-item); (2) team member role(7-item); (3) team process (7-item); (4) team relationship(7-item); (5) intergroup relation (7-item); and finally, (6)problem solving (7-item). Responses were measured on a5-point Likert scale ranging from 1 “Strongly disagree” to5 “Strongly agree”. The scale has high internalconsistency ( =.796). Scoring System: The scale isscored by summing the items, with greater effectivenessindicated by higher scores. The total scores are theaverage of the item ratings and can range from 42-210.

Tool (IV): CRM Knowledge Test: It was developed by theresearchers based on review of related literature [29, 30],to assess staff nurses' knowledge regarding CRM,team task characteristics and team task performance asa pre- and post-test questionnaire. It included 20questions, including: concepts of CRM, taskcharacteristics and task performance; purpose; scope;basic functions of CRM; stages of teambuilding; visionand mission of team; role and functions of team members;safety climate; interpersonal communication; and problemsolving skills. All questions were organized in accordancewith training program content with total score 40 degrees.Scoring System: The Score "two" was given for correctanswer; "one" was given for incomplete answer and"zero" for incorrect answer. For each part of knowledge,the scores of the items were summed up and the totalscore divided by the number of the items. The totalstaff nurses’ knowledge was considered good ifKnowledge 75%, fair 50-<75% and poor knowledge

50%.

Methods:An authorized approval was obtained from theDirector of Damanhour National Medical Instituteand the head of departments in which the study wasconducted. Researchers introduced the research aimsand objectives to nursing administrators for bettercooperation, to inspire staff nurses to activelyparticipate in the study.Tools (I, II, III & IV) were translated into Arabic andtested for its content and face validity by a jury offive experts (Four professors and one assistantprofessor of nursing administration) and accordingly,some modifications were done.

using Cronbach's Alpha Coefficient test: The CrewResource Management (CRM) questionnaire( =.924); Team Task Characteristics Instrument( =.796); and Team Task Performance Questionnaire( =.796).

Pilot Study: It was carried out, to test the clarity,feasibility and applicability of the study tools, on (10%) ofthe study subjects (N= 5 staff nurses), who were excludedfrom the study subjects. Accordingly, some modificationswere done.

Subsequently, the study was conducted throughthree consecutive stages: planning, implementation andevaluation.

Planning and Preliminary Stage: The preliminaryassessment was proposed to identify the studiedsubjects' demographic characteristics; and to assess theirperceptions of CRM; team task characteristics and teamtask performance. The CRM was executed throughtraining program, to determine staff nurses' perceptions ofCRM. Based on the assessment phase, the trainingprogram sessions’ content and media (in the form ofhandout and visual materials) were organized by theresearchers, in Arabic language to suit staff nurses' levelof understanding, to expand and apply their CRMactivities based on the related literature; by practicingtheoretical knowledge; instructional pictures, role playand constructive simulations. The handout was reviewedby the previously mentioned five experts from nursingadministration and nursing education departments.Consequently, some adjustments were done; afterwardsthe last forms were established.

Implementation Stage: Tools (I, II & III) was answered bythe studied subjects, in their clinical units. The programsessions were executed at the clinical setting for all staffnurses by researchers. The handout was distributed toeach one before program's implementation. Six trainingsessions (total 9 hours): the first session lasting 1½hours; followed by four CRM sessions lasting 6 hours;then, fifth and sixth sessions, lasting 1½ hours each.The training program was repeated twice to cover allparticipants.

The first session began with putting the agenda;introducing the training program's aim; icebreaking andassessing staff nurses’ knowledge (tool IV).

Next the four CRM sessions, including: concepts ofCRM; purpose and importance; scope; basic functions ofCRM; interpersonal communication; major domains of


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CRM; application of CRM in clinical areas; and impact of one-way ANOVA with repeated measures; andCRM in health care settings (e.g., ICU). It was Correlation coefficients are used to measure the strengthaccomplished through theoretical content, instructional of the relationship between two variables. Multiple linearpictures and constructive simulation. Following every regression was done using the "Enter" method, to predictsession, staff nurses conducted structured feedback by the dependent outcome from independent predictors bytheir co-workers and the researchers on how to increase Pearson correlation. The unstandardized regressiontheir understandings. coefficient (beta) for each independent predictor was

Afterwards, the fifth and sixth consecutive sessions compared to beta of standardized coefficient, to determinewere developed to cover both team task characteristics the strength of each as an independent predictor, evenand team task performance. It was composed on activities after adjusting the effect of other predictors in the model.related to team, such as: concepts; vision and mission of The F-test was performed to test the overall significanceteam; role and functions of team members; stages of of the model. All statistical analysis was done using twoteambuilding; intergroup relations; and problem-solving tailed tests and alpha error of 0.05. Regarding P value, itskills. was considered that: non-significant (NS) if P> 0.05,

Methods of teaching used were: interactive teaching Significant (S) if P< 0.05, Highly Significant (HS) if P<0.01.strategies (e.g., interactive lectures, group discussion, roleplay and constructive simulations). Instructional media RESULTSwas used; and included handout and visual materialsthrough laptop. Table (1) showed that the mean age of studied nurses

Evaluation Stage: It was elaborated by using the study years and more. According to educational qualifications,tools (tool I, II & III) to determine the effect of nursing nearly half of the staff nurses (45.3%) had Diploma ofCRM training on team task characteristics and team task Technical Nursing Institutes. Above one third of themperformance, at immediately and after three months’ from (37.7%) worked on intensive care unit. The mean years oftraining program implementation. The staff nurses’ nursing experience was 18.2±7.9; compared to 16.8±7.2 forknowledge is assessed before and immediately after the mean years of experience in unit. Nearly three quarters ofsessions (pre- and post-test) (tool IV). staff nurses (73.6%) were married and 64.2% of them had

Ethical Considerations: The aim of the study was The findings of Table (2) illustrated that highlyexplained to subjects and oral informed consent was significant differences were found between total crewobtained from them for their participation in the study. resource management, team climate, interpersonalConfidentiality and anonymity of subjects; as well as their communication, safety climate domains and the threeright to withdraw at any time, from the research, were times of program evaluation (pre, immediately after andassured without any consequences. after three months), where (P=.001, .000, .004, .001),

Data was collected three times (pre; immediately after; respectively. Whereas, a significant difference was foundand after three months from training program between perception of management domain and the threeimplementation), by the previously mentioned tools, times (pre, immediately after and after three months) ofwhich were delivered among the study participants at program implementation (P =.023).their working units. The three tools took approx. from 45 Table (3) indicated that highly significant differencesto 50 minutes/participants. The data was collected for a were found between total team task characteristics, taskperiod of 7 months started from the beginning of significance domain and pre, immediately after and afterDecember 2018 till the end of June 2019. three months from program implementation (P = .000, .001),

Statistical Analysis: Data were collected, tabulated and between task identity, task interdependence domains andanalyzed statistically using an IBM personal computerwith Statistical Package of Social Science (SPSS) version22. The following statistics were applied. Descriptivestatistics: in the form of mean percent score with standarddeviation; and qualitative data were presented in the formof frequencies and percentages. Analytical statistics:The X test is the non-parametric alternative to the2

is 31.47±8.91. Less than half of staff nurses (43.4%) had 40

not attended any training courses.

consecutively. While, significant differences were found

the three times of program implementation (P= .014, .021),respectively.

The results of Table (4) revealed that highlysignificant differences were found between total teamtask performance, purpose and goals, team memberrole, team relationship practices and the three times oftraining program implementation (P= .000, .001, .003, .000)


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Table 1: Distribution of staff nurses according to their demographic characteristics (n=53).

Demographic Characteristics No %

Age (Years)20 - <30 9 1730 - <40 21 39.640 or more 23 43.4 Mean± SD 31. 47±8.91

Educational QualificationsDiploma of Secondary Nursing School 19 35.8Diploma of Technical Nursing Institutes 24 45.3Bachelor of Nursing Sciences 10 18.9

Working unitIntensive care unit 20 37.7Coronary care unit 16 30.2Neurosurgery care unit 17 32.1

Years of Nursing experience 5 -<15years 17 32.115 - <25 years 14 26.4 >25 years 22 41.5 Mean± SD 18.2± 7.9

Years of experience in Unit 5 –<15years 27 50.915 - <25 years 17 32.1 >25 years 9 17.0 Mean±SD 16.8±7.2

Marital statusMarried 39 73.6Not Married 14 26.4

Attending previous training coursesYes 19 35.8No 34 64.2

Table 2: Mean scores of staff nurses Crew Resource Management (CRM), at before, immediately after and after three months from CRM training programimplementation at Damanhour National Medical Institute. (N= 53)

CRM program implementation Friedman test---------------------------------------------------------------------------- ---------------------------------------------

CRM domains Before Immediately after After three months X P2

Team climate 42.78 74.59 69.28 71.8 .000**Safety climate 29.16 41.97 38.70 47.21 .001**Interpersonal communication 31.10 56.73 52.63 29.14 .004**Perception of management 13.25 23.56 22.61 16.3 .023*CRM Total 113.32 163.94 156.59 36.21 .001**

*Significant at level P< 0.05; **highly significant at P<0.01

Table 3: Mean scores of staff nurses team task characteristics, at before, immediately after and after three months from Crew Resource Management (CRM)training program implementation at Damanhour National Medical Institute (N= 53)


Team task characteristics domains Before Immediately after After three months X P2

Task Identity 8.91 16.53 15.76 14.25 .014*Task Significance 9.13 17.31 16.22 11.4 .001**Task Interdependence 8.01 13.75 14.03 9.57 .021*Total team task characteristics 37.81 61.24 57.64 21.79 .000**

*Significant at level P< 0.05; **highly significant at P<0.01


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Fig. 1: Distribution of total staff nurses' knowledge score concerning Crew Resource Management (CRM), team taskcharacteristics and team task performance, pre and immediately after CRM training program (N = 53). Good Knowledge 75%; fair 50-<75%; poor 50%

Table 4: Mean scores of staff nurses team task performance, at before, immediately after and after three months from Crew Resource Management (CRM)training program implementation at Damanhour National Medical Institute (No= 53)


Team task performance practices Before Immediately after After three months X P2

Purpose & goals 18.34 40.7 38.13 39.25 .001**Team member role 14.50 37.09 31.74 27.71 .003**Team process 19.72 36.41 38.17 23.83 .020*Team relationship 16.81 29.39 39.91 49.87 .000**Intergroup relation 17.58 31.21 29.39 17.64 .020*Problem solving 21.46 28.64 26.33 9.23 .040*Total team task characteristics 141.27 253.17 239.79 63.94 .000***Significant at level P< 0.05; **highly significant at P<0.01

Table 5: Correlation matrix between staff nurses' crew resource management, team task characteristics and team task performance at Damanhour NationalMedical Institute (N=53)

Team task characteristics Team task performance--------------------------------------------- -------------------------------------------------------

Study variables r P r PCrew resource management 3.74 .001** 6.31 .000** Team task Characteristics 2.77 .002**Pearson correlation co-efficient (r) *Significant at level P 0.05; **highly significant at P 0.01Interpretation of correlation co-efficient Weak (0.1-0.24) Intermediate (0.25-0.74 Strong (0.75-0.99)

respectively. Although, significant differences were found Table (5) shows that there were highly significantbetween team process, intergroup relation, problem positive correlations between crew resource management,solving practices and the three times of program team task characteristics and team task performanceimplementation (pre, immediately after and after three (where P= .001, .000, .002), respectively.months) (P= .020, .020, .040), consecutively. Table (6) displayed the outcomes of a multiple linear

Fig. (1) demonstrated that staff nurses' knowledge regression analysis designed to predict the team taskscore related to Crew Resource Management (CRM), team performance (as the dependent outcome) from twotask characteristics and team task performance, pre and independent predictors (1 predictor = crew resourceimmediately after CRM training program were good (92%) management; and finally, the 2 predictor = team taskimmediately after implementation; contrasting to (87%) of characteristics). The model shows that the 1 predictor isthem, who had poor knowledge pre-implementation of the strongest independent predictor of the team taskthe training program. performance beta = .875; followed by the 2 predictor beta

st

nd

st

nd


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Table 6: Multivariate analysis linear regression for crew resource management, team task characteristics and team task performance among staff nurses atDamanhour National Medical Institute (N=53)

Unstandardized coefficients Standardized coefficients---------------------------------- -------------------------------Beta SE Beta T P. value

Constant variable 48.242 8.402 5.742 .000**Crew resource management .875 .067 .749 13.012 .001**Team task characteristics .624 .054 .638 11.482 .002**

ANOVAModel df F P. valueR 2 131.828 .000**2

a. Dependent Variable: team task performanceb. Predictors: (constant) crew resource management, team task characteristicsSE: standard error; T: t-test value; R : regression coefficient; F: F-test (ANOVA); ANOVA: analysis of variance; df: degree of freedom. *Significant at level2

P 0.05; **highly significant at P 0.01

= .624, i.e., 87.5 % of the variance of the team task tasks for staff nurses, working in critical care units in theirperformance can be predicted by the independent daily work practices and they aimed to improving theirpredictor in this model. The overall significance of the performance. The level of staff nurses’ satisfaction withmodel was high F= 131.828, P=0.000. management might be diminished by some factors, such

DISCUSSION information, support. Furthermore, the eminence of the

Crew Resources Management (CRM) training have learning new concepts and skills vital for their dailybecome a popular method to increase quality of care and practices.patient safety through considering the role that human This result is in agreement with that of Kuy andfactors play in health care delivery, by learning new Romero [32], who stated that safety climate was improvedconcepts and technique that could be applied in daily after six months compared with the baseline. Additionally,practices [3, 4]. Crew resources management promotes Wu et al. [33] reported that positive changes wereeffective teamwork, improve patient safety, decrease in described by overall participants in their perceptions ofloss of patient lives and overcome ineffective management and patient safety. Furthermore, Mc-Gonaglecommunication [31]. It is recognized that nurses’ training et al. [34] confirmed that safety climate represents eitheris one of the most efficient and cost-effective ways to individual perception or shared group climate perceptionimprove CRM and subsequently team task characteristics regarding safety procedure and practices and behavioraland performance. Therefore, the present study aimed to norms around safety. Additionally, Davis [35] stated thatdetermine the effect of nursing crew resources team members feel that they can explore diverse options,management training on team task characteristics and share ideas, express support toward their colleagues andteam task performance, in intensive care units at that innovation is encouraged by team member’s ability toDamanhour National Medical Institute. embrace risk. In this respect, Beailieu et al. [36] stated that

The findings of the present study revealed that total team climate has been associated with improved patientCRM showed highly significant difference, at the three satisfaction and health outcomes and better access totimes of program implementation (before, immediately care. Moreover, nurses were satisfied with the trainingafter and after three months). Additionally, the CRM and their perceptions of interprofessional, interpersonaldomains (team climate; followed by interpersonal communication and knowledge had improved [37]. On thecommunication; and safety climate) showed highly other hand, kissinger et al. [38] revealed that thesignificant differences; compared to perception of perception of management gave the participants’ the skillsmanagement domain, which was significantly difference of being aware of behaviors that cause negativeat before, immediately after and after three months from individual perceptions.program implementation. This might be due to that tacit, Concerning team task characteristics, the findingstechnical and management skills are acquired through of the present study revealed that highly significanttraining, which will give staff nurses a sense of outcomes differences were found between total team taskaccomplishment. Moreover, team climate, interpersonal characteristics and task significance domain; whereascommunication and safety climate are considered the main significant differences were found between task identity

as: working condition, communication, providing

program indicates that nurses are enthusiastic about


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and task interdependence domains at immediately after pursue similar objectives. Finally, Nullmeyer et al. [48]and after 3 months rather than pre-program summarized that crew resource management had positiveimplementation. This result could be attributed to staff impact on team performance. nurses’ perception, working in critical care units, of their Regarding knowledge related to Crew Resourcevital job meaning and responsibilities and its importance Management (CRM) training program, the majority ofto patient, family and organization. They also consider the staff nurses’ knowledge level was good at immediatelyimpact of their tasks on their patients. This result goes in after implementation; contrasting to the majority ofthe same line with Mondrow [39], who stated that task them, who had poor knowledge pre-implementation ofsignificance can impact positively the organization and its the training program. This may be attributed to staffstakeholders. Additionally, Kozlowski and Ilgen [40] nurses, who receive inadequate training for crewstated that the quantity of personnel teaming resource management in their pre-service education.relationships, training characteristics and objectives This is in line with Hunt [29], who revealed thatrequires maintained optimal performance in specific period knowledge, the capacity to perform and behave withof time. Furthermore, Franck et al. [41] reported that there complete understanding is urgently needed throughwas improvement in team task characteristics after learning, practice and interaction with each other’s; andtraining. On the other hand, Bremner and Carriere [42] that knowledge need to be retained and remembered notstated that task significance had no relationship with only acquired. Moreover, it is concluded that knowledgemeaningful work. and attitudes are learned and shaped by cumulative

Pertaining to team task performance practices, the experiences in life [30]. findings of the present study indicated that highly As regards the correlation matrix and regressionsignificant differences were found between total team task analysis between crew resource management, team taskperformance practices; purpose and goals; team member characteristics and team task performance, the findings ofrole and team relationship, at immediately after and after the present study revealed highly significant positivethree months from program implementation rather than correlations between crew resource management, teampre-implementation. Additionally, significant differences task characteristics and team task performance.were found between team process; intergroup relation and Additionally, the outcomes of a multiple linear regressionproblem solving, at immediately after and after three analysis indicated that highly positive associationmonths compared to before program implementation. between team task performance (as the dependentThese results may be attributed to staff nurses’ outcome) and two independent predictors, namely: crewcommitment and compliance with the educational resource management (approximately 87.5 % of explaineddirectives of the crew resources management training variance); and team task characteristics (approximatelyprogram and its importance to their work in critical care 62.4 % of explained variance). These results may be dueunits. Additionally, staff nurses are faced with different to the attendance of staff nurses to crew resourceissues that need to determine their behaviors and its management training program, as a corrective perspectiverelations concerning their task performance, such as: of system flaws rather than individual shortcomings, anpurpose, role, relationships and problem-solving skills. approach that showed effectiveness in convincingThis is in congruence with Schwartz et al. [43], who professionals. In addition, commitment and noticeablereported that there was an improvement in team support from the unit’s leadership was present. Moreover,performance at post crew resource management training. ICU staff nurses were convinced of the potential gains ofFurthermore, Wai and Wong [44] concluded that crew crew resource management and implementing a newresource management training had positive impact on professional and team identity in their unit. Staff nursesteamwork in clinical nursing education. Nurses also were also formed to integrate the new way of professionalreported improvements at team problem solving and interaction within the ICU. There is greater distinctionrelationships at post program [45]. Moreover, Kyte [46] between ICU nursing crew members’ specific tasksstated that the effect of crew resource management than other units that lead them to perceive theirawareness training on crew members was significantly position specific job duties as ends in themselves.higher for specific teamwork behaviors, which These distinctions would most likely make themconsequently affect behaviors of task performance. In this perceived that they cannot complete the “overall” crewrespect, Harrison and Humphrey [47] postulated that team task alone under any circumstances but with the supportmembers often assume different roles and collectively of structured teamwork behaviors.


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These results are supported with Sommerhoff et al. Believe in staff nurses’ abilities and tasks that are[49], who reported that there was positive impact for important and meaningful, to experience highercrew resource on task performance. Furthermore, Pai [50] satisfaction, to develop a greater passion forindicated that there was positive relation between task teamwork and to become motivated to exert morecharacteristics and task performance. This is also energy and effort to achieve superior teamsupported by Siems et al. [51], who concluded that performance.nursing crew resource management training advocatesfor all team members and offers suggestions on ways to First-Line Nurse Managers Should:structure their concerns in a professional, direct and Inspire the formation of a close-knit cohesiveconcise manner. Moreover, team task characteristics were teamwork climate and communications with othervital for task completion because team members with departments to attend crew resource managementhigher sense of identity perform better than others [52]. training, to improve performance. Finally, Grant [53] summarized that nursing teams perform Assess participants’ use of crew resourcedifferent types of tasks that are vital to nursing care. management skills in clinical settings that representWhen team members perceive that their customary tasks a true change of staff behavior, through differentare meaningful and provide a positive impact to the approaches, such as direct observation. excellence of nursing care; nurses will be more motivated Value the crew resource management-based approachto achieve greater team performance, which is crucial to and significantly improve staff nurses’ knowledge ofthe overall quality of health care. In general, nursing crew teamwork and shared decision-making, to ameliorateresource management training program is designed to the organizational teamwork, through theimprove team skills that is a new concept for staff nurses, management of routine practice in multidisciplinarywho are trained largely to be self-sufficient and environments that is required beyond the boundariesindividually responsible for their daily practices. of professional cultures.

CONCLUSIONS resource management’s influence on

The present study findings concluded that nursing settings; to examine relationship between crewcrew resource management training had positive effect on resource management and safety culture; and toteam task characteristics and team task performance, in evaluate the effectiveness of initial and recurringintensive care units at Damanhour National Medical crew resource management training.Institute, at immediately after and after three months fromtraining program implementation; compared to pre- ACKNOWLEDGMENTSimplementation. Finally, staff nurses' knowledge scorewas good immediately after training program The authors would like to thank all staff nurses, whoimplementation; compared to pre-implementation. were working at intensive and critical care units and

Recommendations: Based on the findings of the study, National Medical Institute.the following recommendations are suggested:

Hospital Administrators Should:Conduct organization-wide crew resource 1. Andrew, R. and G. Wise, 2014. Crew resourcesmanagement training and tailor specific training management and its possible role in nursing risksession to the individual department; which is management. WIT transactions on formation andexpected to improve human-automation team’s communication Technologies. Available at:awareness about the adequacy of team task http://www.witpress.com. ISSN 1743-3517 doi:characteristics distributions and consequently, 10.2495Risk 140221.improving team task performance. 2. World Health Organization (WHO), 2011. PatientUse crew resource management domains to create a safety curriculum guide: multi-professional edition.continuing culture of crew resource management. Geneva: World Health Organization.

Future research is needed to examine crew

performance improvement in different hospital

participated in the training program at Damanhour

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