educating for teamwork coordination in simulated cardiac arrest situations

ORIGINAL RESEARCH

Educating for teamwork nursing students coordination

in simulated cardiac arrest situations

Sissel Eikeland Huseb, Hans Rystedt & Febe Friberg

Accepted for publication 15 January 2011

Correspondence to S.E. Huseb:

e-mail: [email protected]

Sissel Eikeland Huseb MSc RN

PhD Student

University Lecturer

Department of Health Studies,

Faculty of Social Sciences,

University of Stavanger,

Norway

Hans Rystedt PhD RN

Senior Lecturer

Department of Education,

University of Gothenburg,

Sweden

Febe Friberg PhD RN

Associate Professor

Institute of Health and Care Sciences,

Sahlgrenska Academy at University of

Gothenburg, Sweden,

and

Department of Health Studies,

Faculty of Social Sciences,

University of Stavanger,

Norway

HUSEB S.E. , RYSTEDT H. & FRIBERG F. (2011)HUSEB S.E. , RYSTEDT H. & FRIBERG F. (2011) Educating for teamwork

nursing students coordination in simulated cardiac arrest situations. Journal of

Advanced Nursing 67(10), 22392255. doi: 10.1111/j.1365-2648.2011.05629.x

AbstractAim. The overarching aim was to explore and describe the communicative modes

students employ to coordinate the team in a simulation-based environment designed

for resuscitation team training.

Background. Verbal communication is often considered essential for effective

coordination in resuscitation teams and enhancing patient safety. Although simu-

lation is a promising method for improving coordination skills, previous studies

have overlooked the necessity of addressing the multifaceted interplay between

verbal and non-verbal forms of communication.

Method. Eighty-one nursing students participated in the study. The data were

collected in February and March, 2008. Video recordings from 28 simulated cardiac

arrest situations in a nursing programme were analysed. Firstly, all communicative

actions were coded and quantified according to content analysis. Secondly, inter-

action analysis was performed to capture the significance of verbal and non-verbal

communication, respectively, in the moment-to-moment coordination of the team.

Findings. Three phases of coordination in the resuscitation team were identified:

Stating unconsciousness, Preparing for resuscitation, Initiating resuscitation. Coor-

dination of joint assessments and actions in these phases involved a broad range of

verbal and non-verbal communication modes that were necessary for achieving

mutual understandings of how to continue to the next step in the algorithm. This

was accomplished through a complex interplay of taking position, pointing and

through verbal statements and directives.

Conclusion. Simulation-based environments offer a promising solution in nursing

education for training the coordination necessary in resuscitation teams as they give

the opportunity to practice the complex interplay of verbal and non-verbal com-

munication modes that would otherwise not be possible.

Keywords: nursing education, nursing students, resuscitation, simulation-based

environment, team coordination, video recordings

2011 Blackwell Publishing Ltd 2239

JAN JOURNAL OF ADVANCED NURSING

Introduction

Communication failure is responsible for up to 70% of all

patient error (Kohn et al. 2000), which is strongly related

to poor coordination among team members (Cooper &

Wakelam 1999, Xiao and the Lotas Group 2001, Grote et al.

2004). Nevertheless, the opportunities for team training in

healthcare education are seldom offered in the medical

and nursing education curricula (Kyrkjeb et al. 2006,

McConaughey 2008). Previous research has emphasized the

need for verbal communication to maintain effective coordi-

nation in resuscitation teams but very little research has been

done on how successful coordination takes place in simula-

tion-based environments (Manser et al. 2008). In the present

study, the research interest is extended to non-verbal com-

munication modes, such as gestures and body movements,

and the significance of such modes in team members efforts

to coordinate their actions.

Mannequin-based simulations are increasingly used as

educational methods for training team skills (Anderson

2008). Such simulators include a computerized full-body

mannequin, which can be programmed to simulate the

physiological conditions of various medical disorders and

responses to the users interventions (Fritz et al. 2008).

Simulation thus allows for interactive and engaging activity

by recreating important aspects of a clinical event without

exposing patients to risk (Dieckmann 2009). Of central

concern in the present study is the potential of simulation

with a full-body mannequin to give opportunities for nursing

students to learn and practise team coordination skills.

Research on simulations indicates that training with manne-

quin-based simulators contributes to improved communica-

tion and teamwork on the part of nursing students, thus

leading to enhanced patient safety (Flanagan et al. 2004,

Medley & Horne 2005, Fritz et al. 2008). However, there is a

lack of knowledge concerning what aspects of the simulation-

based environment are critical for students development of

communication skills (Salas & Cannon-Bowers 2001).

Research on coordination within teams

In health care, coordination is an essential component of

successful teamwork (Manser et al. 2008, Salas et al. 2008).

The concept of coordination in the present study is under-

stood as the act of managing interdependencies between

activities performed by actors to achieve purposeful perfor-

mance (Hindmarsh & Pilnick 2002, 2007). However, few

studies have investigated team coordination in emergency

care and more research is needed to identify the conditions

necessary for the development of successful coordination in

simulation settings (Manser et al. 2008). Most of these

studies apply behavioural observation methods to the inves-

tigation of coordination within teams (Cooper & Wakelam

1999, Xiao and the Lotas Group 2001, Grote et al. 2004,

Manser et al. 2008). The results of these studies reveal that:

resuscitation teams need a coordination leader in order to

perform effectively (Cooper & Wakelam 1999), the require-

ment on coordination increases in line with task complexity

(Xiao and the Lotas Group 2001) and effective teams are

characterized by adapting their coordination strategies to the

requirements of the situation, i.e. employing more implicit

coordination in routine situations and more explicit coordi-

nation in critical situations (Grote et al. 2004).

One key finding in research on coordination is the

distinction between explicit and implicit coordination

(Manser et al. 2008). Explicit coordination refers to team

members use of clearly addressed messages to coordinate

actions (Serfaty et al. 1993), while implicit coordination is

based on a shared but tacit understanding of the task

requirements, which have usually been established in advance

(Wittenbaum et al. 1998). Some contradictions exist in

current research on coordination. On the one hand, a number

of studies suggest that implicit coordination is both prevalent

and effective in high workload situations where resources for

explicit coordination may be limited (Entin & Serfaty 1999,

Grote et al. 2004). On the other hand, research indicates that

lack of explicit coordination in critical situations leads to

coordination breakdowns (Xiao and the Lotas Group 2001).

It has also been claimed that explicit coordination is

associated with higher resuscitation team performance

(Cooper & Wakelam 1999, Tschan et al. 2006).

Explicit communication is one of the cornerstones of a

training programme called Crew Resource Management

(CRM) (for an overview, see Rall & Gaba 2005). CRM is

used in healthcare team training to promote safe and effective

communication among team members and is widely

acknowledged to enhance team performance (Rall &

Dieckmann 2005). Research demonstrates that CRM train-

ing produced positive reactions in trainees, although it has

been difficult to find evidence for transfer to clinical settings

(Salas et al. 2006).

All research reported above investigated teamwork perfor-

mance by assessing verbal communication alone or verbal

and non-verbal communication as separate entities, while the

way in which speech and gestures are used simultaneously to

achieve coordination was not taken into account. In contrast,

the present study applies a research tradition rooted in

interaction analysis, which investigates the way in which

speech and bodily behaviour mutually constitute each other

in the organization and production of moment-to-moment

S.E. Huseb et al.

2240 2011 Blackwell Publishing Ltd

actions in real time (Goodwin 2000). These studies focus on

how team members establish a mutual understanding of the

situation at hand and how effective coordination of actions is

achieved on a collaborative level (Hindmarsh & Pilnick

2002, 2007). Hindmarsh and Pilnick (2002) demonstrated

how successful coordination between individuals was

achieved in anaesthesia teamwork. The findings suggest that

the team members learn to read the implications of

embodied human behaviour for the specific demands of

teamwork. The results of Hindmarsh and Pilnicks (2007)

study show how the body constitutes an important resource

for effective real-time coordination in anaesthetic teamwork.

Both verbal and non-verbal responses are thus important for

displaying their understanding to each other about how to

continue with the task at hand (cf. Heath & Luff 1992).

Consequently, not only verbal communication has to be

addressed in order to understand the foundations of coordi-

nation of purposeful actions, but also non-verbal communi-

cation involving bodily aspects of human conduct. In line

with this research, the present study focuses on how students

interactively employ both verbal and non-verbal modes of

communication in coordinating joint actions in simulated

real-time tasks.

The study

Aim and research questions

The overarching aim of the study was to explore and describe

the communicative modes students employ to coordinate the

team in a simulation-based environment designed for resus-

citation team training. The following research questions

guided the analysis:

What is the significance of verbal and non-verbal commu-nication modes, respectively, and how do these interplay in

the coordination of resuscitation?

How do the students coordinate their activities to accom-plish joint assessments and actions in the simulated resus-

citation team?

Methods

This study has an explorative and descriptive design (Polit

& Beck 2010). Observation through video recordings was

chosen due to the ability to capture complex interactions in

natural social settings (Heath et al. 2010). Video data

allow for different kinds of methodological approaches and

both a content analysis and an interaction analysis were

performed, which will be elaborated further in a section

that follows.

Participants

A total of 81 students (72 female and 9 male) in the last

semester of a 3-year nurse education programme, with an

average age of 27 years (range: 2253 years), participated in

the study. The students were divided into 14 groups, each of

which comprised in average six members. Both genders were

represented in four groups, whilst the rest consisted of female

students only. The average age of the groups varied from 23

to 33 years. The participant group was comparable with

other student groups in Norwegian nursing education

programme with respect to age and gender (Rykenes &

Larsen 2010). Five female faculty members aged between 34

and 60 (average age 49) with 2 years of experience in

simulation were involved as facilitators.

Ethical considerations

The study was approved by the Norwegian Social Science

Data Services (NSD) and the university. Consent forms were

signed by the nursing students and the faculty and confiden-

tiality was guaranteed. All those who were asked agreed to

participate.

Setting

The study was performed in a simulation centre in Norway

using a patient simulator (SimMan) controlled by a monitor

located in an adjacent operator room. The mannequin that

was placed in a bed exhibited clinical signs such as palpable

pulses, breathing movements and sounds. A speaker located

in the mannequins head transmitted the voice of the

operator, thus giving the impression that the patient could

talk. The placement of the two video cameras (A and B) used

for the recordings can be seen in Figure 1. A microphone was

positioned in the ceiling.

The nursing students preparation prior to the simulation

session

Before starting the simulation session, the students attended

lectures about individual skills training in Basic life support

(BLS). According to European Resuscitation Guidelines from

2005, BLS refers to checking for response, opening the

airway to check for breathing and if absent, providing 30

chest compressions and two breaths (Handley et al. 2005)

(Figure 2).

Prior to the simulation session, each group was given a

briefing about the functioning of the mannequin. The

facilitator demonstrated how the medical equipment worked

JAN: ORIGINAL RESEARCH Educating for teamwork


and introduced the learning objective, i.e. teamwork training

for cardiac arrest situations. In this study the simulated

patient was a 71-year-old woman, who had suffered an upper

femur fracture and had been moved to the rehabilitation unit.

The patient had a history of angina pectoris.

At each simulation, the teams comprised three students.

They were instructed to act in a similar manner to that

used in the clinical field during the 15-minute simulation.

The three remaining students in each group and the

facilitator were present in the room and observed the

simulation and in the next simulation scenario, the students

changed roles.

Data collection and analysis

The whole data material consisted of 28 hours of video

recordings of the simulated cardiac arrest events collected in

February and March 2008 by the first author.

The video recordings were systematically reviewed with

focus on the students coordination of their activities. The

most demanding parts of employing the algorithm turned out

to be the first three steps (Figure 2) which correspond to three

phases in the simulation scenarios: (1) stating unconscious-

ness, (2) preparing for resuscitation and (3) initiating resus-

citation. These parts, in all 28 groups, were transcribed (on

average 3 minutes, 48 seconds) to include each students

comments, gestures and actions and others responses to them.

A closer data analysis was performed in two steps. First,

content analysis was conducted to identify the form of

communicative actions occurring in all groups (Krippendorff

2004). All researchers (SEH, FF, HR) coded a selection of the

sequences together, and then the main author (SEH) coded

the whole data corpus. The entire coding was then discussed

among the authors until consensus was reached.

Further, all communicative actions were marked and coded

with respect to whether they involved (1) verbal, (2) non-

verbal and (3) simultaneous use of verbal and non-verbal

communication. In addition, these modes were divided with

respect to whether they concerned the accomplishment of

joint assessment or assembling joint actions. Secondly, the

number of all communication actions that occurred in the

data was counted. A full list of categories and numbers,

including examples, is given in Appendix 1.

In a second step, an interaction analysis was performed in

line with the recommendations of Heath et al. (2010) and

Jordan and Henderson (1995). Initially, collective analyses

were performed on seminars at the Linnaeus Centre for

Research on Learning, Interaction and mediated Communi-

cation (LinCS) in Sweden.

Recurrent patterns in the participants coordination of the

BLS algorithm were identified and specific attention was paid

to the interplay between different communication modes.

Three examples from one simulation session were selected for

a detailed analysis of the complexity of the interplay between

speech and gestures. These served as representative examples

of patterns of interaction in the sense that they illustrated the

28 simulations as a whole. By presenting an in-depth analysis

of one group it was possible to see how every new action was

based on previous activities of the group members (cf. Heath

& Luff 2000, Hindmarsh & Pilnick 2002).

Des

k

B

Table

Door

Door

Chair Chair ChairA

One-way-mirror

Operators chair

Figure 1 The simulation room.

Step 1. No movement or response from the patient

Step 2. Open airway, check breathing for 10 sec.

Step 3. If there is still no response and the patient is not breathing normally, start 30 chest compressions

Step 4. Provide cycles of 30 compressions and 2 rescue breathing

(Handley et al. 2005)

Figure 2 Basic life support (BLS).

S.E. Huseb et al.


Findings

The findings are presented in the three phases identified,

corresponding to the three-first steps in the BLS algorithm:

(1) Stating unconsciousness, (2) Preparing for resuscitation

and (3) Initiating resuscitation. Secondly, the result of

counting all the communication modes revealed certain

emerging patterns, which are described for all groups in each

phase. Thirdly, an in-depth analysis is presented of the same

phases, illustrating the complexity of the interplay between

different communication modes exhibited by the findings.

Stating unconsciousness

In the event of a suspected cardiac arrest, the first step in the

BLS algorithm is to check whether the patient is unconscious

(Figure 2). Identifying this point in time is critical, as it

signals when the next step in the algorithm should be carried

out. For the team to agree on this presupposes a mutual focus

achieved by a series of stepwise changes of position, enabling

close monitoring of the mannequins response to questions

and tactile stimulation. All of these actions place extensive

demands on the students to align themselves to each others

actions in a timely fashion.

Figure 3 shows the numbers of different communication

modes in the phase of stating unconsciousness. In this phase

we identified two subcategories: joint assessment and joint

action. Joint assessment subcategories imply that the patients

vital functions are monitored and identified while joint

actions imply actions to be taken to prepare for or to initiate

resuscitation. In all instances of verbal, non-verbal and

simultaneous use of both verbal and non-verbal communica-

tion, the subcategory joint assessment received the highest

number compared to that of joint action(153 vs. 34).

Examples of the simultaneous use of verbal and non-verbal

modes in the joint assessment subcategory were naming and

questioning the patient simultaneously with touching

and shaking the mannequin for a response. Verbally stating

the need to call 113 and doing it at the same time was an

example of using dual modes in assembling joint action

(Appendix 1).

How such coordination is enacted in detail is here shown

by foregrounding the activities of one of the groups. A typical

example is illustrated below (Figure 4), in which student 2

(S2) and student 3 (S3) stand on each side of the bed close to

the patient and student 1 (S1) is positioned in front of and

facing the desk occupied by the task of preparing an injection

(Figure 4i). The question Are you there- Brenda? by S3 is the

initial step in checking consciousness.

As the mannequin cannot simulate body movements or

skin colour changes, verbal response is the only means of

checking the level of consciousness (Figure 2, step 1). S3s

question Brenda, is everything okay with you?-hello (Fig-

ure 4ii) is thus a way of finding out whether there is any

response from the simulated patient. Shared attention is

seldom achieved immediately, but occurs in several steps.

This is illustrated in Figure 4i, in which S1 has assumed a

body orientation in front of and facing the desk, which means

that she was occupied by the task of preparing an injection.

S1 responds to S3s question by turning her head 90 degrees

towards the mannequin, while her torso and legs remain

oriented to the desk (ii). This body torque projects instability

in relation to the home position, which signals change so that

the head and torso will once again be brought into a

convergent alignment (Schegloff 1998). One second later S1

had rotated her body 160 and was now facing the bed,glancing at the mannequin (iii). Although S1 was engaged in

another activity, she simultaneously monitored the actions of

her colleagues. In this case, the question Brenda, is every-

thing okay with you?-hello addressed by S3 to the manne-

quin triggered S1 to undertake the next step, i.e. to leave the

desk and move towards the bed. The lack of an answer to the

questions put to the mannequin and the stepwise changes in

position were thus essential in creating a shared focus on the

level of consciousness (Heath & Luff 1992). The absence of

an answer from the patient has an important meaning in this

particular setting in which checking consciousness is a part of

the familiar algorithm and unconsciousness is expected to

70605040302010

Verbal Nonverbal Verbal + Nonverbal

Joint assessmentJoint action

0

Figure 3 The total number of communi-cation actions quantified within the

different communication modes in the

phase of stating unconsciousness.



occur. The problem here consists of identifying exactly when

this happens and when the next step should be initiated. In

turning away from less urgent tasks and towards the

mannequin, the students are able to indicate to each other

preparedness for the occurrence of this critical state.

A common pattern in the majority of groups was that the

students simultaneously combined verbal modes such as

naming and questioning with a demonstration of checking

with their senses to determine if the patient was unconscious.

The students seldom explicitly asked other students for help

or discussed what should be done in such situations. Overall,

this points to the fact that the interplay between verbal and

non-verbal communication is critical for agreeing on when

the simulated patient is unconscious.

Preparing for resuscitation

One part of applying the algorithm, although not addressed

in the model itself, is to prepare for and facilitate ventilation

and compressions by bending down the back rest, removing

the pillows and placing the patient in a prone position. Jointly

arranging for this position demands that the students are at

all times able to predict what subsequent actions they are

supposed to perform.

Figure 5 shows the numbers of communication modes in

the phase of preparing for resuscitation. Non-verbal com-

munication in the joint action subcategory received the

highest number compared to all other subcategories in

both verbal communication and simultaneous use of both

S3 The arrows illustrate the orientation of S1s head, torso and legs.

(3601) S1 is standing at the desk preparing an injection with her back tothe others. S2 is on the right side of the bed looking at the mannequin.S3 is on the left with her hands on the mannequins shoulder, looking at themannequins face and asking Are you thereBrenda?. The patient does not respond. S2 utters Brenda.

S1

S2

i

S3(3604) Once again S3 tries to obtain a response by asking Brenda, iseverything okay with you? hello. S1 reacts to the lack of a response byturning her head towards the mannequin without moving her torso andlegs.

S1 S2

(3605) S1 then takes one step forward towards the bed, glancing at themannequin. S2 says Hello Brenda.

ii

S3

S1

S2

iii

Figure 4 Stating unconsciousness.

S.E. Huseb et al.


communication modes (108 vs. 7). Examples of non-verbal

modes were when students gave each other space, as

demonstrated through their movements. Another example

of such actions is how they aligned themselves with each

others actions in simultaneously bending down the backrest

and then lifting up the mannequin to remove the pillows

(Appendix 1).

The interaction analysis of this phase reveals how the

students are regularly able to coordinate their assessments

and actions by positioning themselves very close to each other

around the bed. In this way, they were able to monitor each

others actions that did not require as much verbal commu-

nication as in the previous phase. This is illustrated in

Figure 6i, where S2 and S3 are standing on each side of the

bed and S1 has moved towards the bedside table to conduct

the next step, i.e. placing the patient in a prone position

(Figure 4i).

This initial spatial arrangement does not allow for eye

contact. Nor is there any verbal exchange between S1 and S3.

S1 does not request S3 to move to the right, nor does S3 ask if

she should move (ii). Instead S3 reads S1s body language

and uses it as a resource for attuning to her fellow student by

changing her own position (Hindmarsh & Pilnick 2002,

2007). Figure 6ii illustrates how the students regularly place

themselves very close to each other around the bed in ways

that facilitate the monitoring of each others actions. In other

words, they create a formation that gives the necessary

conditions for the effective exchange of glances, gestures and

words (Kendon 1990). The spatial arrangements establish

public, shared foci of visual and cognitive attention including

1009080706050403020100



Figure 5 The total number of communi-cation actions quantified within the

different communication modes in the

phase of preparing for resuscitation.

(3606) S1 walks towards the bedside table, moves it to the left andplaces herself at the head of the bed. This position allows her to pushdown the back of the bed to lay the patient flat.

(3607) When S3 notices that S1 has moved the bedside table andplaced her body between it and the bed, she shifts slightly to the rightto give S1 space in which to accomplish her task with the bed. S1simultaneously issues the following instruction Lets see - takedown the back. S2 responds to S1s instruction by pushing thehandle and taking down the back of the bed from the right hand side.They accomplish the task together and with parallel movements inorder to quickly position the patient horizontally.

S3

S3

S1

S1

S2

S2

i

ii

Figure 6 Preparing for resuscitation.



the mannequin with which they are working, and explains

the extensive use of non-verbal communication modes

(Figure 5). When giving the instruction Lets see take

down the back (ii) S1 uses the adverb down, indicating a

specific direction to the student behind the bed. Although the

recipient of the verbal directive is not explicitly mentioned by

name, S2s immediate response shows that she realized that it

was intended for her. S1s request Lets see take down the

back functions as a coordinating utterance that makes it

possible for the team to go ahead with the preparations for

cardiopulmonary resuscitation (CPR). Note that this action

occurs before the students had confirmed the absence of

breathing, which is the second step in the BLS algorithm

(Figure 2). The reversed order demonstrates that the students

anticipate a cardiac arrest and the actions that are supposed

to follow.

Initiating resuscitation

Steps 2 and 3 in the algorithm are to ensure that the airways

are open, to check breathing and to identify if absence of

response and breathing persist. This is a critical phase in

applying the algorithm since it serves as an indication of

cardiac arrest and signals the need to start CPR immediately

(Figure 2).

Figure 7 shows the number of the different communication

modes in the phase of initiating resuscitation. Joint action

received the highest number in all modes of communication,

indicating the need for starting CPR. Examples of assembling

joint actions included verbal directives to remove the head-

board or to ask for medical devices. Non-verbal communi-

cative modes mainly involved pointing at the oral airway or

the defibrillator as a request to other team members to

retrieve or hand them over. Simultaneous use of verbal and

non-verbal communication included saying, for example,

you must connect the oxygen, at the same time as looking

and pointing at the oxygen device. Nevertheless, joint

assessment occurred frequently in this phase, and included,

for example, the interplay between confirming cardiac arrest

verbally and simultaneously removing the headboard or

medical devices (Appendix 1).

The last example shows in detail how the interplay of

verbal and non-verbal communication modes enabled them

to assess when the crucial signs of cardiac arrest were present

and how these, in turn, indicated the point of time at which

to take action (step 2 and 3 in the BLS algorithm) (Figure 8).

This point in time was preceded by actions such as inspecting,

listening and trying to sense chest heaves so that the others

could see them. It is noteworthy that the mannequins

inability to simulate breathing through the mouth means

that it is only possible to check for the absence of breathing

by a visual inspection and by means of the tactile senses (i).

Through the visible monitoring of the mannequins breath-

ing and simultaneous utterance No, she is not breathing, S3

gives the other participants with important information

about the patients ventilation status, which becomes avail-

able through temporal interplay between communicative

methods such as inspecting, sensing and listening. The

utterance is connected with a search for thorax movement

by leaning over the mannequin and simultaneously feeling for

breathing movements by laying the hand on the mannequins

chest. This indicates to the rest of the team that the proper

examinations have been conducted, while a remark about

ventilation status signals the need to continue. S1 responds by

removing the glasses from the mannequin, bending down,

glancing at its chest and reformulating S3s information

about the absence of breathing, now using a well-known

institutional term No breathing (ii). This, in turn, functions

as a signal for action. The statement indicates the start of

resuscitation and several other actions that are supposed to

follow in the BLS algorithm, i.e. preparation for ventilating

the patient and initiation of chest compression. The statement

No breathing changes the scenario from an everyday care to

a lifesaving activity, assuming that the timely actions set out

in the BLS algorithm are applied. In a similar vein as in the

preceding sequences, the mutual aligning to each others

actions and non-verbal communication modes forms the

basis for joint agreement on how to proceed. In addition, No

8070605040302010



0

Figure 7 The total number ofcommunication actions quantified within

the different communication modes in the

phase of initiating resuscitation.

S.E. Huseb et al.


breathing serves as a definite signal for the team members to

start CPR.

Discussion

Limitations

Although the generality of the communication pattern found

in the present study are supported by the studies of other

healthcare teams, there might be some limitation to the

conclusions due to the fact that all students were recruited

from only one nursing programme in Norway. They may

differ from non-Norwegian students with respect to cultural

and educational background as well as gender and age. Even

though only the first steps in the algorithm were analysed

(since these turned out to be most challenging for the

students) this may contribute in some part to understanding

coordination, alongside a study of all the steps.

Discussions of results

The findings reveal three phases of coordination, stating

unconsciousness, preparing for resuscitation, initiating

resuscitation. Coordination of joint assessments and actions

in these phases involved a broad range of verbal and non-

verbal communication modes that were necessary for

achieving mutual understandings of how to continue to

the next step in the algorithm. This was accomplished

through a complex interplay of taking position, pointing,

and through verbal statements and directives. The results

reveal how the interplay between verbal and non-verbal

communication is vital in achieving coordination in teams.

Aligning to each others bodily movements and positions is

often enough to assemble joint actions. Joint assessments,

however, often require both verbal communications in

addition to non-verbal modes. The same applies, for

instance when prompt and timely actions are to be initiated,

such as at the start of CPR.

The result of counting all communication modes revealed

that verbal and non-verbal communications were essential

in joint assessment of when unconsciousness occurred and in

joint initiation of CPR. In a study on coordination in

anaesthesia it was showed that during assessment, planning

and decision-making the simultaneous use of verbal and non-

verbal communication were a prevalent coordination mech-

anism (Manser et al. 2008). The monitoring of other team

i

S3

S1

ii

S2

(3612) S3 places her right hand on the mannequins chest and bendsdown to listen for breathing sounds, looking and feeling with her righthand for thorax movements and saying No, she is not breathing.

(3619) S1 responds to S3s statement by removing the patients glasses,bending down, glancing at the mannequins chest and verifying S3sstatement by saying No breathing. S3 responds by removing the duvetand the kidney bowl from the mannequins torso.

S2

S1

S3

Figure 8 Initiating resuscitation.



members activities was also found to be salient, and

consistent with the findings of the present study in the phase

of preparing for resuscitation. Our findings are also consis-

tent with previous research on coordination, demonstrating

that non-verbal communication is effective in the coordina-

tion of high workload situations (Entin & Serfaty 1999,

Grote et al. 2004).

In all, our results are consistent with previous studies that

point to the necessity of training broader aspects of

coordination than mere verbal communication. Moreover,

a wide range of verbal and non-verbal modes of commu-

nication were necessary to agree on how to proceed and

how to perform joint and timely actions. This included

employing speech, gestures, eye contact, artefacts (the

mannequin) and the physical environment. The particular

set of resources available in the setting constituted the

conditions necessary for the students to align themselves to

each other (Goodwin 2000). The actions could not have

been performed without the students being able to perceive

each others bodily movements in combination with verbal

communication. Throughout the simulation session, the

different types of communication modes mutually comple-

mented each other, thus providing the basis for successfully

carrying out the steps of the BLS algorithm. The framing of

the situation as one in which the BLS algorithm should be

realized was another central condition for attributing

important meanings to speech, actions and artefacts. The

prompt response to the statement No breathing (Figure 8)

presupposes that its meaning is taken for granted by the

participants. In this way, the application of the algorithm

itself offers a context in which both directed speech and

indirect communication convey messages that are under-

stood in specific ways.

The relevance of simulation as an arena for training is

demonstrated by the fact that the team members communi-

cative actions for achieving coordination in the simulation

were very close to competent clinical teamwork. Hindmarsh

and Pilnick (2002, 2007) revealed how the body forms a

critical resource for successful coordination in anaesthesia

teamwork. Although many of the tasks carried out in the

practice of anaesthesia differ from those in the simulated

cardiac arrest situation, their characteristics are similar. The

students worked as a team, the task of which was to

collaboratively monitor and support the patients vital

functions. In contrast to Hindmarsh and Pilnicks (2002,

2007) findings, the inexperienced students, who were not

trained in teamwork prior to the simulation, were unable to

rely on predefined roles and a prearranged division of labour

to the same extent as professionals. Consequently, they had

to meet unforeseen needs for joint actions by inventing

communicative actions to achieve coordination on the spot.

Since professional teams are generally able to anticipate what

will come next, they are also able to coordinate their work

more effectively. That new teams perform in a less anticipa-

tory fashion than experienced teams was also showed in a

study comparing experienced surgeon teams with newly

qualified teams (Zheng & Swanstrom 2009). Nevertheless,

the findings in all the settings reveal the critical importance of

the unnoticed and taken for granted methods of coordinating

teamwork.

What is already known about this topic

Poor coordination among resuscitation team memberscan compromise patient safety.

In healthcare education, students are seldom trained inteamwork.

Previous research on effective team coordination hasemphasized the necessity to practice verbal forms of

communication in simulation training.

What this paper adds

Verbal communication is not in itself sufficient forachieving coordinated actions.

Coordination in resuscitation teams presupposescommunicative actions that involves a combination of

bodily conduct and gestures and verbal communication.

Perceiving other team members bodily movements andverbal actions is vital in the coordination of

resuscitation teams.

Implications for practice and/or policy

Although verbal communication is essential for effectivecoordination, the necessity of non-verbal

communication for successful team coordination should

also be acknowledged.

Simulations offer promising solutions since they givepossibilities for training the entirety of coordinated

actions in teams that would otherwise not be possible.

Non-verbal communication necessary for coordinationshould be included in briefing and debriefing sessions in

simulation-based team training.

Research on simulation should focus on how verbaland non-verbal forms of communication are

intertwined in teamwork and how this can be

systematically trained in simulations for the purpose of

improving patient safety.

S.E. Huseb et al.


The results highlight how speech and body language

mutually constitute the prerequisites for joint assessment

and action. Consequently, this is something that needs to be

accounted for in the training of nurses and allied professions.

These findings differ from previous research on coordination

within teams, which suggests that verbal communication

alone or verbal communication and bodily conduct as

separate entities can explain how coordination is achieved

(Cooper & Wakelam 1999, Xiao and the Lotas Group 2001).

An approach to getting things done by employing verbal

communication alone as presupposed in CRM training (Rall

& Dieckmann 2005) may imply that important aspects of

human action are overlooked and remain seen, but unno-

ticed (Garfinkel 1967).

One implication for resuscitation team training suggested

here is the importance of instructors including all aspects of

the communication process to promote the learning of

coordination skills. A second implication is that the contra-

dictory results of previous studies (Cooper & Wakelam 1999,

Xiao and the Lotas Group 2001) on coordination, i.e.

whether verbal or non-verbal communication is more effec-

tive for successful coordination within teams, might be

explained by the dynamic changes in communication modes

related to the development of the ongoing situation, as

illustrated here. Whether verbal communication or gestures

are more effective in emergency care cannot be answered in a

general way, since it depends on how situations develop as a

result of moment-to-moment interactions. A third implica-

tion is that the distinction between explicit and implicit

coordination can be somewhat misleading. Obviously acts

referred to as implicit coordination, such as taking positions,

gesturing and non-directed speech, are essential for explicat-

ing the team members understanding of each others actions

and what to do next.

There are huge differences between the simulator and

human beings. Nevertheless, the present results indicate that

the students treated the mannequin as a legitimate repre-

sentation of a human being and employed communicative

actions to achieve coordination relevant for clinical

practice. It is also apparent that this was not an effect of

the simulator itself, but rather that the perceived relevance

was shaped in and through the interaction between the

participants and with the technical environment. For the

students, the mannequin was not just a plastic doll, but a

sufficiently realistic representation of a human being for the

purpose of simulating resuscitation. In the words of

Garfinkel (1967, p. vii) they exhibited an accountable

understanding of the cardiac arrest situation and were

engaged in treating the simulation as real for all practical

purposes.

Conclusion

The present study emphasizes the tacit, often taken for

granted aspects of teamwork as essential components of

coordinated action and illustrates how simulation-based

environments give possibilities for training important facets

of teamwork that would not otherwise have been possible.

Moreover, it points to the necessity of including these aspects

in simulation-based team training instructions and debriefing

sessions in nursing education. We suggest that future research

on simulation should not focus on verbal- and non-verbal

communication as separate entities. To further improve

patient safety it is necessary to address how different forms

of communication are intertwined in coordinated action and

how these can be systematically trained by means of

simulations.

Acknowledgements

This research was financially supported by The Laerdal

Foundation for Acute Medicine. The analytic work has been

carried out in cooperation with The Linnaeus Centre for

Research on Learning Interaction and Mediated Communi-

cation in Contemporary Society (LinCS) in Sweden. We wish

to thank Professor Eldar Sreide (Stavanger University

Hospital, Norway) for his valuable contribution to the study

and Erica Johnson, PhD, MPhil (University of Gothenburg,

Sweden) and Peter Dieckmann, PhD, Dipl.-Psych. (Danish

Institute for Medical Simulation, Denmark) for thoughtful

and valuable comments on earlier versions of the manuscript.

Funding

This research received no specific grant from any funding

agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

No conflict of interest has been declared by the authors.

Author contributions

SEH, HR and FF were responsible for the study conception

and design. SEH performed the data collection. SEH, HR and

FF performed the data analysis. SEH, HR and FF were

responsible for the drafting of the manuscript. SEH, HR and

FF made critical revisions to the paper for important

intellectual content. SEH obtained funding. SEH gave

administrative, technical or material support. HR and FF

supervised the study.



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Appendix 1. A full list of categories and numbers including examples of all communication modes in allphases and groups

Category Stating unconsciousness

Subcategories Codes and numbers Examples*

Verbal communication Verbal communication

Joint assessment Naming the patient 25 Nora, Nora

Questioning the patient for response 12 Nora, Nora is everything okay

with you?

Validating fellow student (unconsciousness) 3 Yes, she is unconscious

Asking for response and answering no response 1 Nora, Nora, are you awake? No,

we dont get

Asking fellow students for respiration status 2 Is she breathing?

Describing respiration 1 Her breathing is very shallow

Stating absence of pulse 3 There is no pulse

Stating absence of breathing 8 She is not breathing

Stating cardiac arrest 10 Now its cardiac arrest

Fellow student confirming absence of breathing 1 Right, she is not breathing

Questioning is it cardiac arrest 1 Is it cardiac arrest?

Joint action Directive 7 Hallo, get the emergency suitcase

Directive to fellow student 2 Get the heart board

Directive to call 113 1 Will you call 113?

Stating to call 113 1 Ill call 113

Non-verbal

communication

Non-verbal communication

Joint assessment Shaking the mannequin 5 One student shakes the mannequin

(for response)

Looking at fellow student 8 One student looks at a fellow

student and gives an assessment

Touching the mannequin 6 One student touches the

mannequins shoulder

(for response)

Monitoring blood pressure 1 One student puts the blood

pressure monitor on the

mannequins arm

Sensing chest heaves 16 One student (bends down), looks

and listen for chest heaves

Sensing pulse 3 One student puts two fingers on

artery radialis

Bending 17 One student bends down (to look

and listen for chest heaves)

Joint action Looking at fellow students 7 One student looks at a fellow

student and asks a question

Interplay between

verbal and

non-verbal

communication

Interplay between verbal and non-verbal

communication

Joint assessment Naming and touching the mannequin 15 Nora, Nora and touches the

mannequins shoulder

Naming and shaking the mannequin 5 Nora, Nora and shakes the

mannequins shoulders

Asking the patient and sensing response 6 Nora are you here? and touches

the mannequins chin



Appendix 1. (Continued)


Naming and lifting the head and looking 1 Nora, and looks and lifts the

mannequins head

Stating lack of pulse and sensing 3 There is no pulse and puts two

fingers on the artery radialis

Joint action Stating absence of breathing and fast moving 1 She is not breathing and runs for

the door

Stating absence of breathing and sensing 2 She is not breathing, looks and

listens for chest heaves

Stating cardiac arrest and glancing at the two fellow

students

2 Now it is cardiac arrest and looks

at fellow student

Stating cardiac arrest and sensing 2 It is cardiac arrest, cardiac arrest

and puts her hand on the

mannequins chest

Asking whether cardiac arrest has occurred, looking

up and body movements

5 Is it cardiac arrest?, looks at

fellow students, turns around and

goes to the door

Confirming cardiac arrest and sensing chest heaves 1 Yes, it is cardiac arrest and puts

her hand on the mannequins

chest

Verbal statement of calling 113 and doing it 1 I will call 113 for help and picks

up the phone

Directing and looking at fellow student 2 Can you monitor the blood

pressure and looks at fellow

student

Category Preparing for resuscitation


Verbal

communication

Verbal communication

Joint action Directing 4 Can you run and get the emergency suitcase

Instructing fellow student to

lay down the back rest

1 Lets see

Joint assessment Repeating naming the patient 1 Nora, Nora

Questioning about respiration 1 Is she still breathing?

Stating absence of breathing 3 She is not breathing, she is not breathing normally

Non-verbal

communication


Joint action Bending down the backrest 24 Two students bend down the back rest so the bed is

in a prone position

Removal of pillows 18 Two students remove the pillows from under the

mannequins head and put them on the table

Doing movements simultaneously 15 Two students lift up the mannequin and remove

the pillows

Orientation to each

other

6 Two students stand opposite to

each other, ready to act

simultaneously

Placing and

removing/moving/fasten

artefacts

8 One student moves the bed

table/moves the head

board and places it on the floor

S.E. Huseb et al.




Moves to give another

space

16 One student moves to remove

the headboard and fellow

student changes position

Looking at fellow students 12 One student looks at fellow

students to synchronize

actions

Interplay between

verbal and

non-verbal

communication

Interplay between verbal and non-verbal communi-

cation

Joint action Directing and looking 1 Can you run and get the emergency

suitcase and looks at fellow student

Directing and moving 3 Lets see and student 1 helps student

2 to lay down the back rest

Joint assessment Stating absence of breathing and

sensing and touching the patient

1 She is not breathing, she is not

breathing normally and senses chest

heaves with the hand

Stating absence of breathing

and gazing

1 She is not breathing, she is not

breathing normally and looks at

fellow student

Category Initiating resuscitation


Verbal communication Verbal communication

Joint action Directive to call 113 15 Will you call 113?

Directive to start compressions 15 Will you start compressions?

Directive to remove the headboard 15 Remove the headboard

Directive to start ventilation 15 Can you give some blows?

Stating start of compressions 5 Ill start compressions

Asking to call the physician 1 Should we call the physician?

Asking for medical device 2 Will you pick up the mask for me?

Asking to open the patients mouth 1 Can you open the mouth so I can put in the

oral airway?

Naming artefacts 1 Heart board

Stating to go and get medical devices 3 Ill go and get the heart board, AED and

emergency suitcase

Correcting behaviour (give injection) 1 You dont need to give the injection now

Joint assessment Stating cardiac arrest 2 Shes in cardiac arrest

Validating cardiac arrest 1 Yes, I think we have a cardiac arrest here

Asking to give information 7 What did the physician say about the treatment

Answering what was said about the

patients status

1 The physician will arrive in ten minutes

Non-verbal

communication






Joint action Body movements to get artefacts 15 One student moves around the bed

to get the heart board

Pointing at artefacts 4 One student speaks in the phone and points at the

AED

Synchronic body movements 6 Two students lifts up the mannequin to place the

heart board

Placing artefacts 1 One student moves the breakfast tray from the bed

table to the desk

Collecting and placing artefacts 4 One student removes the emergency suitcase and

AED from the floor to the desk

Lifting the mannequin and placing

headboards

1 Two students lift the mannequin and the third

student places the headboard under its chest area

Changes of body position, turning

head and torso

5 One student turns her head and torso towards fellow

students while speaking into the phone: we have a

cardiac arrest here

Body moves and showing artefacts 3 One student moves from the desk to the bed, holding

a syringe in her hand

Taps fellow student and hand over

the oral airway

1 One student talks into the phone while he picks up

the oral airway and taps a fellow student

Grab fellow students arm 1 One student grabs fellow students arm

Anticipating each others actions 7 One student picks up the bag-mask with one hand.

Seeing this action, a fellow student lifts the

mannequins head and removes the pillows with

her other hand

Looking at fellow students 18 One student speaks into the phone and looks at a

fellow student

Joint assessment Sensing 3 One student puts her hand on the mannequins chest

Listening, looking and sensing 1 One student bends down, looks, listens and uses her

senses to detect chest heaves

Interplay between verbal and

non-verbal communication

Interplay between verbal and non-verbal communi-

cation

Joint action Directing and moving headboard

while moving bodies

7 Help me lift her up. Fellow student lifts up the

mannequin and places the head board under the

mannequin

Directing, looking and pointing 11 You must connect the oxygen and looks at fellow

student, moves his eyes to the oxygen device, and

points at it

Directing action and body movements 1 Heart board and bends down, grabbing the heart

board

Directing and gripping fellow students arm 1 You start doing compressions and grabs fellow

students arm

Directives to call and tapping, gives the oral

airway to fellow student

1 Put it down (the AED) and picks up the oral airway

and taps fellow student on the shoulder and hands

over the airway

Stating not to inject medication and looking

at fellow student

2 I dont think I should give the injection now and

gazes at fellow student

Statements (bring AED) and body movements 2 Yes, Ill go and pick up the medical devices and

goes to the door

Asking about information and body movements 2 What did they say (on the phone)? and turns

around to pick up the AED

Naming the oral airway/head board and looking

and/or pointing/sensing/body movements

19 The oral airway and points at the oral airway on

the desk, looking at fellow student

S.E. Huseb et al.




Stating what it is,

its purpose and

demonstrating

1 Heres a syringe with Afipran (Metoclopramide), Ill

give it intramuscular and moves from the desk to

the bed, holding a syringe in her hand

Joint assessment Stating and sensing lack of

chest heaves

2 It doesnt feel like shes breathing and holding one

hand on the mannequins chest

Stating cardiac arrest,

looking and

receiving artefacts

1 Its cardiac arrest and looks at fellow student, who

hands over the head board

Confirming cardiac arrest

and body movements,

removing artefacts

19 No life signs and moves behind the bed and

removes the headboard

*The author has tried to give non-ambiguous examples for each sub categories. However, depending on the context, the reader imagines a

statement might fall into different subcategories.

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