Optimizing Medical Teaming on Resident Based Teams

Study Overview
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Brief Summary
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The main objective of this study is to evaluate the colocalization of internal medicine residents on one clinical inpatient hospital floor for all general medicine block rotations during the 2019-2020 academic year. Specifically, the aims of the study are to determine if co-localization improves familiarity with nursing staff, which in turn, improves team work, psychological safety, patient care and reduces burnout. The investigators' hypothesis is that co-localization will increase familiarity between residents and nurses and result in improved psychological safety, team work and patient outcomes.

Detailed Description
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Teamwork is critical in delivering high quality medical care. Failures in team communication and coordination have been cited as significant contributors to medical errors. In large teaching hospitals, patients receive care from transiently formed teams of nurses and residents who may only work together for as little as two weeks, as residents rotate through many clinical floors due to the complexity of resident scheduling. Unlike more established teams that work together over long periods of time, these transient groups are called teaming; a process where a group of diverse providers, with different roles, outlooks and levels of professional training transiently come together to carry out complex tasks. (Reference: Dr. Amy Edmondson, Harvard Business School) A key risk in teaming is the lack of familiarity of team members as studies suggest familiarity promotes an environment of psychological safety, where team members feel safe speaking up, asking for help and admitting errors. These skills are important for both team work and patient safety. The investigators hypothesize that in large residency programs where resident rotate on multiple floors, it is possible to improve the quality of teaming by increasing the frequency with which smaller groups of residents and nurses work together. As a result, the investigators propose a randomized controlled trial on an inpatient general medical floor to study the effect of co-localizing residents with nursing staff. One cohort of residents will be assigned to complete all general medical rotations on a single floor for the academic year. The investigators will assess the impact on psychological safety, team work and patient care. The investigators hypothesize by co-localizing residents with nursing, while these teaming are still transient, the slight increase in familiarity will promote a culture of psychological safety and improve team work. If benefits are found, resident scheduling can be adjusted in subsequent years.

Official Title
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Optimizing Medical Teaming on Resident Based Teams

Conditions
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Inter-professional Relations

Intervention / Treatment
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* Behavioral: Co-Localization with Nursing


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: All incoming PGY-1 residents who volunteer to be randomized Exclusion Criteria: Any incoming PGY-1 resident who declines to be randomized

Ages Eligible for Study
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Minimum Age: 24 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Single Group Assignment
Interventional Model Description: The investigators plan to randomize 16-18 Post Graduate Year (PGY)-1 residents in internal medicine at Massachusetts General Hospital from the possible 74 PGY-1 incoming residents who agree to partake in the study to one general medicine clinical floor for the academic year. These co-localized residents will complete 16-20 weeks of scheduled rotation time on White 9. Similarly, the investigators plan to randomize 6-8 PGY-2 residents from a possible group of 64 PGY-2 residents who agree to participate in the study to one general medical clinical floor for the academic year. These participants will complete 4-6 weeks of scheduled rotation time on White 9. Rotations will be completed in the normal 2 or 4 week block rotations, randomly assigned throughout the academic year.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Co-localized Residents<br>Investigators plan to randomize 15 PGY-1 residents in internal medicine from the possible 74 PGY-1 incoming residents who agree to partake in the study, to one general medicine clinical floor for the academic year. These co-localized residents will complete 16-20 weeks of scheduled rotation time on White 9 | Behavioral: Co-Localization with Nursing<br>* Co-localize 15 residents to one of 6 general medical floors to complete all 8 weeks of general medicine on this floor<br>|
| No Intervention: Normally Schedule Residents<br>The control arm will consist of 18 PGY-1 residents who are scheduled by the residency program's algorithm in the usual fashion to complete general medicine rotations on 5 difference clinical floors. The 18 active comparator participants will be selected based on completing one of four general medicine rotation on the control floor White 8. These participants will then be followed while completing the remaining general medicine rotations on all clinical floors. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Teamwork assessed by Simulation about Shortness of Breath | Simulation of an inpatient clinical scenario will be conducted. This simulation about shortness of breath will be run with teams consisting of two residents and two nurses. These interdisciplinary teams will be asked to manage a patient together. All residents and nurses in the study will be asked to participate in the simulation. The simulations will be recorded. Blinded reviewers will view these simulations later and will score the team's performance using an published Oxford NOTECH simulation teamwork assessment tool. The assessment tool is designed to identify higher functioning teams by evaluating leadership, communication, shared mental models and utilization of resources. | This simulation will be conducted at 6 months in this 12month study | 
| Teamwork assessed by Simulation about Negotiation with Angry Patient | Simulation of an inpatient clinical scenario will be conducted. This simulation about negotiating with an angry patient will be run with teams consisting of two residents and two nurses. These interdisciplinary teams will be asked to manage a patient together. All residents and nurses in the study will be asked to participate in the simulation. The simulations will be recorded. Blinded reviewers will view these simulations later and will score the team's performance using an published Oxford NOTECH simulation teamwork assessment tool. The assessment tool is designed to identify higher functioning teams by evaluating leadership, communication, shared mental models and utilization of resources. | This simulation will be conducted at 12 months in this 12month study | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Psychological Safety | A survey tool has been developed for both residents and nurses. The survey tool asks questions using a 5 point Likert scale about psychological safety, communication and teamwork. The questions were modified based on prior published work by Dr. Amy Edmondson at the Harvard Business School. The survey will be used to evaluate the residents and nurses perception of teamwork and psychological safety. | Residents and Nurses will be surveyed at 6 months in this 12 month study | 
| Psychological Safety | A survey tool has been developed for both residents and nurses. The survey tool asks questions using a 5 point Likert scale about psychological safety, communication and teamwork. The questions were modified based on prior published work by Dr. Amy Edmondson at the Harvard Business School. The survey will be used to evaluate the residents and nurses perception of teamwork and psychological safety. | Residents and Nurses will be surveyed at 12 months in this 12 month study | 
| Communication between Nurses and Interns | A time motion study will be conducted where an observer with an Apple iPad will observe rounds with nurses and interns. The observer will record the amount of time each individual is speaking, the length of rounds and the number of patients rounded on. | Observation will start at 6 months in this 12 month study and continue through study completion, an average of 6 months |