Crisis Resource Management: Evaluating Outcomes of a Multidisciplinary Team : Simulation in Healthcare

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Empirical Investigations

Crisis Resource Management: Evaluating Outcomes of a Multidisciplinary Team

Jankouskas, Tara MS; Bush, Mary Chasko MD; Murray, Bosseau MD; Rudy, Sally BSN; Henry, Jody BS; Dyer, Anne Marie PhD; Liu, Wenlei MS; Sinz, Elizabeth MD

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Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare 2(2):p 96-101, Summer 2007. | DOI: 10.1097/SIH.0b013e31805d8b0d
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Crisis resource management (CRM) is a team-training program that teaches nontechnical skills such as: collaboration, communication, task management, teamwork, and leadership1. The purpose of this study was to evaluate improvement in the nontechnical skills of a multidisciplinary team of pediatric residents, anesthesiology residents and pediatric nurses following participation in the CRM educational program. Self-efficacy theory guided the teaching method used in the CRM program. The Collaboration and Satisfaction about Care Decisions instrument 2 and the Anesthetists' Nontechnical Skills System 3 served as outcome measures. Seven multidisciplinary groups were studied with a total of 40 subjects. A significant increase was found in posttest scores for perceived collaboration and satisfaction with care and in numerical ratings of observed team skills following the CRM program. The results suggest multidisciplinary team participation in the CRM program increased perceived team collaboration, satisfaction with care, and observed teamwork skills.

Despite the knowledge and skill level of nurses and residents demonstrated in basic and advanced life support courses, errors and inefficiencies in patient management occur due to human factor issues. This problem is magnified in a patient crisis situation due to the pressure to act quickly with the stress of caring for an unstable patient. Nurses and physicians practice the technical skills of patient resuscitation through basic and advanced life support courses every 2 years. Technical skills such as use of a bag-valve-mask, an automated external defibrillator, and other emergency equipment are practiced in these courses. In addition, rapid cardiopulmonary assessment and the use of algorithms are taught and practiced to provide physicians and nurses with a standardized cognitive framework for managing the patient's condition. However, the nontechnical skills of a crisis such as collaboration, communication, teamwork, task management, and leadership are also highly critical to effective patient management. The limitation of the American Heart Association's life support curriculum for teamwork training is documented.4 In addition, two landmark and comprehensive reports by Kohn et al.5 and the Institute of Medicine6 recognize the need for teamwork training in healthcare to improve patient outcomes. Improved execution of nontechnical skills in a crisis can improve efficiency of care delivery and potentially have a beneficial impact on patient outcomes.2,5,6

Crisis resource management (CRM) at The Penn State Milton S. Hershey Medical Center is an educational program using an experiential learning method of simulation to teach nontechnical skills in a crisis situation.7 Similar to the life support courses, CRM education provides nurses and physicians with a cognitive framework combined with an opportunity for practice. However, the cognitive framework involves the nontechnical skills of managing a crisis rather than the technical skills of life support. The learning objectives focus on the nontechnical skills in a crisis such as collaboration and leadership. Participants in this program practice management of patient crises through challenging scenarios using a high-fidelity human patient simulator in a simulated, yet realistic, clinical environment followed by debriefing of team performance with a simulation instructor.

Several studies have documented positive outcomes from CRM education including perceived clinical utility by the participants in CRM, improved perceived nontechnical skills by participants in CRM, and improved observed nontechnical skills by expert observers who evaluate crisis scenario performance.1,8–11 However, only a few studies have used a multidisciplinary team in applying CRM education.9,11 Most studies have used homogenous groups such as a group of radiology residents or anesthesiology residents. Response to a patient crisis typically involves a multidisciplinary team; therefore, practicing CRM skills and evaluating the outcomes is most relevant to a similar team.

Self-efficacy theory by Albert Bandura guides the instructional approach of simulation applied to the CRM educational program.12 Application of learning theory provides the necessary framework for an effective educational method for CRM content delivery to the learner. Self-efficacy is one's belief in one's ability to perform successfully in a given situation.12 According to this learning theory, practicing skills through challenging simulations can lead to increased self-efficacy. A high level of self-efficacy related to a particular skill set is associated with future successful performance.13,14 Therefore, practicing the nontechnical skills of communication, collaboration, leadership and teamwork through patient crisis simulations may increase learner self-efficacy in a crisis that may promote successful performance. Positive outcomes resulting from theory-guided, adult education build evidence-based practice for educators.

The research questions for this study are:

  • Can a multidisciplinary CRM program of pediatric nurses, pediatric residents, and anesthesiology residents at Penn State Hershey Medical Center positively impact perceived collaboration?
  • Can a multidisciplinary CRM program of pediatric nurses, pediatric residents and anesthesiology residents at Penn State Hershey Medical Center improve nontechnical skills?


Study Design

A nonexperimental pre/posttest design was used with a convenience sample of nurses and residents from Penn State Milton S. Hershey Medical Center.15 Institutional Review Board approval was obtained prior to the study. The study began in August 2005 and ended in December 2005.

Sample and Setting

A convenience sample of seven multidisciplinary groups of three pediatric nurses, two pediatric residents, and an anesthesia resident from our institution were studied. The total number of subjects was 40. The pediatric resident pairs for each group included a second- and third-year resident. The anesthesia resident for each group was a first- or second-year resident. The medical center is a 600-bed, tertiary care center located in rural southcentral Pennsylvania. The hospital campus, Milton S. Hershey Medical Center, serves as a satellite campus and clinical site for Penn State University.


Subject consent to participate was obtained prior to the program. Subjects also signed a confidentiality agreement for the scenario content and for peer behaviors during the simulated scenarios. Each multidisciplinary group attended a 3-hour CRM program (Fig. 1). The 3-hour CRM program included (in the order listed): an introduction to the simulation laboratory and the pediatric human patient simulator capabilities and functionality, management of one of two pediatric crisis scenario embedded with challenges and distractions, presentation of CRM principles followed by a debriefing of the videotaped pediatric crisis scenario with discussion of CRM skill application, management of the second pediatric crisis scenario of equal difficulty, and a debriefing of the second videotaped pediatric crisis scenario. Equality of the two scenarios was assured using a methodology for scenario development described by Bush et al.16 The order of the two pediatric crisis scenarios was randomized. Each CRM program was facilitated by a simulation instructor who completed a 3-day simulation instructor training at the Institute for Medical Simulation, Cambridge, MA (

Figure 1.:
Study methodology.

Outcome Measures

Each subject completed the Perceived Collaboration and Satisfaction about Care Decisions (CSACD) at the end of each of the two scenarios (Fig. 2). The CSACD includes 2 elements: perceived collaboration (four questions), and perceived satisfaction about care decisions (two questions). All questions were rated on a 7-point numerical scale. Demographic questions of sex, role (nurse or physician), years of experience, and advanced life support certification (pediatric or adult; yes or no) were added to this instrument. Baggs demonstrated content validity of the CSACD instrument using nursing and medical experts in collaborative practice.2 A prior study demonstrated construct validity through factor analysis of the collaboration items that explained 75% of the variance.2 Factor loadings for the collaboration items were 0.82–0.93. Internal consistency using Cronbach's alpha was 0.93.

Figure 2.:
Perceived Collaboration and Satisfaction about Care Decisions.

The Anesthetists' Nontechnical Skills (ANTS) System was used as an observational marker system for assessment of nontechnical skills for the multidisciplinary group in each scenario (Fig. 3). The ANTS system has four categories: task management, teamworking, situation awareness, and decision making. The raters included an experienced pediatric nurse who is a pediatric advanced life support instructor and simulation instructor and an anesthesiology resident who is certified in basic and advanced life support. They were blinded to the scenario order and completed the ANTS system for each scenario after viewing the videotaped scenarios following the program. The raters discussed the appropriate numerical rating from 1 to 4 on each element within each of the four categories on the ANTS system to determine the final element rating. The element ratings within each category were averaged to obtain a final rating for the multidisciplinary group on each of the four categories on the ANTS system. Fletcher et al.3 demonstrated content validity using a panel of expert anesthesiologists and an internal consistency using Cronbach's alpha of 0.79-0.86. Although the ANTS system was created for application to groups of anesthesiologists, use of the tool in this study was appealing for three reasons: 1) the team behaviors in the tool appear to represent the generic competencies of any effective healthcare team,17 2) the tool has demonstrated reliability and validity,3 and 3) clear instructions for use and recommendations for training on the tool are available from the authors of the tool.

Figure 3.:
Anesthetists’ Nontechnical Skills System.

Data Analysis

For the CSACD outcomes, a repeated measures linear model was fit to test for a difference in pretraining and post-training scores. Gender, years of experience, role and Advanced Life Support certification were included as covariates in the model, and multidisciplinary group was included as a random effect. Unlike the CSACD outcomes, which are measured on an individual level, the ANTS outcomes are scored for each multidisciplinary group, resulting in only 7 observations. No statistically significant differences were found among the 7 multidisciplinary groups with respect to gender, years of experience, role and Advanced Life Support certification. Therefore, the ANTS outcomes pretraining and post-training scores were considered paired, and the difference in pretraining and post-training group scores analyzed without inclusion of covariates. Due to the small sample size (n = 7), and scale of the ANTS outcomes (4 point numerical scale), the Wilcoxon signed rank test was performed to analyze the paired differences.

All data analyses were generated using SAS software, Version 9.1 of the SAS System for Windows (SAS Institute Inc., Cary, NC). A significance criterion of 0.05 was used for all statistical tests.


Of the seven multidisciplinary groups, five groups had six members and two groups had five members, resulting in a total of 40 participants. Of the 40 participants, 27 (67%) were female and 21 (52%) were male. Twenty-four (60%) had Pediatric Advanced Life Support certification, 7 (18%) had Advanced Cardiac Life Support certification, 8 (20%) had both, and one had neither. The median number of years experience was 3 years (interquartile range 1.6-6.5). For the CSACD outcomes, a statistically significant difference in pretraining and posttraining collaboration and satisfaction scores was found with mean differences of 1.42 (P < 0.0001) and 1.27 (P < 0.0001), respectively. For the ANTS outcomes, only teamwork was statistically significant with a median difference of 0.8 (P = 0.03). ANTS pretraining and posttraining teamwork scores for each group are illustrated in Figure 4. Pretraining and posttraining summary measures for all outcomes, as well as the pretraining and post-training differences, can be found in Table 1.

Figure 4.:
ANTS pretraining and posttraining teamwork scores.
Table 1:
Participant Scores for the CSACD (7-point scale) and ANTS (4-point scale)


The crisis response team for the Children's Hospital at Penn State Hershey Medical Center includes a second- and third-year pediatric resident, an anesthesia resident, and three pediatric nurses. The CRM program was applied to this group to simulate the typical crisis response team.

The CSACD instrument measures perceived collaboration, a concept similar to teamwork. In this study, subject's perceived collaboration and satisfaction about care decisions demonstrated a significant increase following the CRM training. This finding is extremely pertinent because collaboration and teamwork have been implicated in reducing errors, improving patient outcomes, and increasing staff satisfaction.2,5–6 The true clinical implication of this increase in perceived collaboration and satisfaction about care decisions is unknown; however the investigators believe that the mean increase of >1.0 point on the 7-point numerical scale is potentially clinically significant. Therefore, we hope that the positive collaboration will transfer to the clinical environment particularly because the multidisciplinary groups consisted of subjects who work together in the same clinical unit versus randomly created groups of subjects from various clinical units.

The categories of nontechnical skills on the ANTS system are task management, teamwork, situation awareness, and decision making. Within each ANTS category are 3–5 observable behavioral elements. A significant increase on the teamwork element was noted. The teamwork element was easy to observe. The congruent improvement of perceived collaboration and in observed teamwork after the CRM program provides validation of the positive impact of the CRM program in this conceptual area.18,19 The concept of collaboration is broader than teamwork; however, teamwork is an element of collaboration. Although the significant increase in the teamwork rating following the CRM training is encouraging, the actual clinical implication of this increase is unknown. Future studies can correlate collaboration ratings with other outcomes such as team clinical error rate or team intervention response time to help establish a desired benchmark rating.

The lack of significance in the elements of teamwork, situation awareness, and decision-making could be a result of various factors. The raters found the elements of situation awareness and decision making difficult to visualize and assess on video if the participants did not think aloud. These elements include cognitive processes such as recognizing and understanding, anticipating, identifying options, and balancing risks. In addition, due to background noise during the simulation, all communications were not clearly audible on the videotape. As raters, we depended on hearing the team conversation to assess the elements of situation awareness and decision-making. To improve rater accuracy on scoring these elements, future study will require improved voice reception of participants and clear identification of participant behaviors that represent each of these elements in a given scenario.

The element of task management demonstrated a pretest to posttest increase of 0.5 but was not statistically significant. This is surprising because the raters found the element of task management easily visualized by observation. Perhaps this 0.5-point improvement on the small 4-point scale is clinically significant despite lack of statistical significance. Based on this study and the novel application of the ANTS system in this setting, it is impossible to determine. Future studies can correlate ANTS ratings with other outcomes such as team clinical error rate or team intervention response time to help establish a desired benchmark rating.

These results support the evidenced-based application of Bandura's self-efficacy theoretical framework as an effective instructional approach to CRM education. Using simulation to teach the nontechnical skills of CRM provides an extremely powerful experiential learning experience.7 Participants have opportunities to practice and master the desired skills. This learning is further enhanced by facilitated debriefing of the videotaped scenario in which learners can view their team behaviors and responses to the crisis while applying the CRM principles. Skill mastery (skill practice), verbal feedback (debriefing), and the video review (vicarious learning) are all concepts within Bandura's self-efficacy theory.12 According to this theory, application of these concepts to educational approaches promotes learner self-efficacy which is associated with successful future performance.13,14 To truly discern the impact of the teaching method of CRM, further study comparing various teaching methods is indicated.

In summary, these results indicate that the CRM training increases perceived team collaboration, satisfaction with care and observed team work skills. Educational programs that can build collaboration and teamwork in a crisis are extremely valuable to promoting an organized and effective team response. Despite regular training in life support skills, patient crises are typically characterized by chaotic team response.20–22 Fragments of evidence from various health care studies indicate the critical importance of multidisciplinary collaboration and teamwork in a crisis. Specifically, the value of collaboration is supported from studies of collaboration2,23 and from studies of related concepts including communication,22,24,25,26 task management,22,26,27 and situation awareness.24,26,28 The outcomes from this study clearly support the evidence-based value of CRM for providing a framework for achieving multidisciplinary collaboration in a crisis.


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