Verbal pressure made by a team leader can decrease the quality of chest compressions during cardiopulmonary resuscitation: a pilot study

Introduction

The accuracy and precision of the activities performed are among the most important aspects of the work of medical professionals. The quality and safety of the patient care provided significantly decreases without these aspects [1]. Nevertheless, these are not the only qualities that a medical professional must have. In addition, proficient teamwork skills or coping with pressure and stress from the environment are required. Numerous procedures carry a high immediate risk of loss of life or health, which places an additional psychological burden. Despite the increased pressure from the environment, the medical professional must focus his attention as maximally as possible on the activities performed. In many cases, the medical procedure performed is more complicated and the cooperation of many people is required for its implementation, e.g. the process of blood transfusion [2]. Despite international recommendations and guidelines, more than 85% of incidents are still due to errors in this transfusion process [3]. Thus, the human factor is a strong determinant affecting the correctness of the procedures performed and the number of errors made [4]. It is also an effect determined by other factors such as work organization, staff deficiencies and low morale.
Currently, there is a lack of scientific data in the literature outlining the impact of a team leader’s negative influence on other team members. In particular, there is a lack of data that interrogates both the short- and long-term effect of verbal pressure on team members. There is a knowledge gap that would accurately determine the effect of stress on a specific group of activities, divided into those that are physical and those that definitely require a mental component. Filling the gaps presented will perhaps help draw attention to the importance of practising non-schematic/precise activities in simulation conditions. The objective of this study is to evaluate the verbal pressure of the team leader on the efficiency of team members, distinguishing between precision and typically physical activities such as chest compressions.

Material and methods

Current study

Our study was prospective in design and was conducted at the Powiślański University in Kwidzyn. We used simple randomization using Research Randomizer.
The study does not require the bioethics committee approval due to the fact that conducted simulation studies are not subject to the evaluation of bioethics committees. All participants gave written voluntary consent to participate in the study. The students were not remunerated.
Twenty seven Polish paramedic students (third semester out of six included in the study curriculum) were randomized into two groups. Participants took part in a low-fidelity simulation scenario of emergency department trauma resuscitation. Members of both groups were asked to call a serology laboratory and order 0 Rh (–) red blood cell concentrates for life-saving transfusion. They were asked to find the number in the hospital phone book (10 pages), each phone number contained 9 digits. Numbers in the directory were grouped by the department or facility. The number to be found was placed on the sixth page. During this activity 14 students (control group) were working without any additional comments from anyone while the leader was urging 13 students (study group) using previously prepared words and phrases: ‘hurry up’, ‘faster’, ‘we need to perform a transfusion quickly’, ‘it is very close to cardiac arrest’. The pressure was made by the team leader (physician). The tone of the voice was firm, but no shouting was used. Just after entering the phone number into their own cell phone, the accuracy of this activity was checked as well as the time was recorded. Immediately after this part participants were asked to perform 2-minute chest compressions. Average depth, correctness of chest recoil and compression speed rate were being examined with Resusci Anne quality cardiopulmonary resuscitation medical manikin (Laerdal Medical AS, Norway).
Afterwards, participants were asked to evaluate their level of stress and satisfaction connected with their work on a 0–10 scale (where 0 means no stress and no satisfaction while 10 means a high level of stress and the highest level of satisfaction). Participants’ heart rates (HR) were measured before and immediately after the scenario.
Statistical analysis was performed with Statistica 13 software. c2 test, Mann-Whitney U test and Spearman’s correlation test were applied since collected data was not parametric. Equality of both groups has been considered as a null hypothesis. The level of significance was set at p-value = 0.05 and all results are presented as average ± standard deviation. Post hoc POWER analysis has been performed with jamovi software with jpower plugin.

Previous study [5]

Results of chest compression quality was combined with previous results. Detailed material and methods are described in the previous manuscript [5]. Before the chest compression task the students were asked to prepare an endotracheal intubation kit basing on the SPEED BOMB checklist. Six of them were rushed by the team leader (similarly to the current study) while eight were working without any comments. Then they were performing 2-minute chest compressions (as in the current study).

Results

Current study results

General results of the study and control groups are presented in Table 1. The most important difference between both groups is correctness of the phone number noting down the phone number (with a higher rate of errors in the study group).
Incorrect chest recoil is connected with a higher percentage increase of the HR (U = 26.5, p-value = 0.002). Current study results combined with previous research [5]
As the methodology of chest compression quality measurement is similar in both studies, here a combined analysis is presented. Table 2 shows general results of groups of both research studies. As seen in the table, participants differ in the chest compression depth differs between two studies, so this parameter was excluded from further analysis.
Table 3 presents differences between the study and control groups combined together (current and previous [5] research studies). As we can notice, verbal pressure made by a team leader leads to a higher incidence of incorrect chest recoil and a higher percentage increase in the HR.
Self-reported stress (irrespective of whether the verbal pressure is made or not) was negatively correlated with the chest compression rate – participants who feel more stressed compress fewer times per minute (R = –0.364, p-value < 0.05). These parameters were even more connected if we exclude the participant who reported the highest stress level (10/10). After exclusion of one participant, the parameters were as follows R = –0.456, p-value < 0.05. This finding is presented as a graph in Figure 1. On the other hand, individuals who compress too fast (> 120 per minute) reported a significantly lower stress level in comparison to others (3.46 ±2.78 vs. 5.18 ±2.36; U = 108.00, p-value = 0.038) (Figure 2). Similarly, according to the results of the current study, combined populations also had a higher increase in the HR while performing incorrect chest recoil (U = 89.50, p-value = 0.008). This is presented in Figure 3.

POWER analysis

Since the key results of this study are only marginally significant (p = 0.050 and 0.045), post hoc POWER statistics have been performed. For c2 tests, Cohen’s values and POWER were calculated. For the correctness noting down the phone number (n = 27) w = 0.377, POWER 49.8% and for correctness of chest recoil (n = 41) [jw] w = 0.313; POWER 51.8%. In order to get POWER level of 80%, the total number of participants would be required: n = 56 in case of noting down the phone number and n = 80 for the chest recoil parameter. POWER statistics for the independent samples Student’s t-test (with the current sample size) are presented in Figure 4. POWER level of 80% is obtained for true effect size (d) 0.900 and in case of effect size 0.500, the POWER level is 34.4%. Discussion
The participants in the study group who were exposed to verbal pressure by the team leader performed worse in both activities requiring greater precision and performed more inaccurately in typically physical activities such as cardiopulmonary resuscitation cardiopulmonary resuscitation (CPR).
In our work, we can distinguish two types of activities performed by medical professionals. One of them requires maximum focus and precision, and is not practised under safe teaching conditions. In contrast, the other chest compression activity is a schematic skill, practised repeatedly during the course of the study, and one in which the muscle memory plays a large role. This unusual division makes it possible to conclude that exerting pressure results in decreased efficiency in both groups of activities. In contrast, in the study by Cumming and Harris [6], the anxious group recorded a decrease in accuracy only in the decision task and no change in the other task. This suggests at least two possible reasons for such a difference when compiling the results. Accuracy on high-precision and higher-focus tasks depends on the degree of adaptation of individuals to the stress perceived. Therefore, it would be appropriate to consider expanding the scope of simulations during the course of the study. The idea is to include situations in which students themselves struggle with the pressure of their surroundings while for example, dialing a phone number for the transfusion, calculating the dose and administration of drugs. The inclusion of such scenarios could help students reduce the tremendous stress when starting their careers and develop ways to adapt to difficult situations [1, 7]. In this context, it would also be appropriate to consider the conditions of the simulations conducted and the possible aids. The research performed so far shows that high-fidelity simulations that allow the student to face the problem directly are the most effective way of teaching [8, 9]. Meanwhile, the study specifically notes the relevance of conducting simulations with additional emotional stressors. According to the results presented here, such simulation led to more anxiety, but correlated with better skill performance after this course [10]. In addition to simulations, applications, diagrams, checklists are also good methods to reduce the risk of making errors and cognitive overload in difficult situations [11, 12]. Implementing adequate preparation for paramedics and better stress control can help reduce exposure to burnout and resulting suicide attempts [13, 14]. The other possible reason for our results is the effect of acute stress on memory. Many of the effects of stress are selective for specific phases and types of memory. A meta-analysis conducted recognizes that post-encoding stress tended to enhance memory, while stress on retrieval impaired memory, and stress on encoding could enhance or impair memory depending on key moderators [15]. Whereas the study accurately indicates working memory impairment, cognitive flexibility and cognitive inhibition under stress [16]. At this point, it is also worth citing the research showing that stress increases arousal and negative emotions and negatively affects decision-making, but in a different way for men and women [17]. On a related note, there is a need for further research evaluating the effects of stress, but with a specific gender distinction.
In our study, there was no statistically significant difference between the vital parameters of the participants in the two groups. In terms of the students’ subjective assessment of stress, there was also no statistically significant difference. These results may be the effect of physical and psychological conditions of the participants – the lack of a significant increase in blood pressure and HR may be due to better physical training of the participants. In the study, participation in CPR alone was shown to increase stress at baseline [18, 19]. The overlap between these two components may be an explanation for our receiving such results. Additionally, it further indicates the need for a further analysis of the condition of paramedics during stressful situations. Regarding the students’ self-assessment, our results may be the effect of intentionally under- or overestimating their assessment [20]. This may be caused by a disturbed view of oneself among students, low self-esteem. This is in contrast to the study by Bjørshol et al. [21], in which the presence of socioemotional stress increased subjective workload and frustration. At the same time, without affecting the quality of cardiopulmonary resuscitation. In another study, self-reported stress and anxiety were found to correlate well with physiological changes in blood pressure, self-rated motivation, self-efficacy and mental workload [22]. The analysis of our work showed a deterioration in the accuracy of the activities performed, therefore we suspect a significant influence of the psychological component of the students.
The biggest limitation of the work is the size of the groups. The relatively small number of participants may have significantly affected the results of this study. Therefore, the interpretation of the results of this work should be adjusted for the number of participants. The absence of further validation of the study participants’ responses to the self-assessment of perceived stress is another limitation that may have affected our results. In this aspect, we are aware that the study participants may have deliberately underreported scores of perceived stress. The use of supplementary questions may possibly help to assess the reliability of the responses given by the participants. The scenario presented in the study is also a limitation of the work, as it does not reflect the true responsibility felt during emergency situations in real life. The participants’ private experiences also be another limitation. The small number of participants definitely increases the chance of coming across someone among the participants who has already performed similar activities as part of an internship/volunteer service.

Conclusions

The behaviour of the team leader can affect directly the action of team members in an adverse way. The exertion of verbal pressure induces stress that increases the risk of human errors in both precise actions like searching for a specific phone number and actions that are mastered in a schematic way – CPR. There is a need for more studies specifying possible dangers from team leaders’ verbal pressure. Even if the data is limited at this moment, verbal pressure should be eliminated in emergency team leadership which requires educational efforts.

Disclosures

1. Institutional review board statement: Not applicable.
2. Assistance with the article: None.
3. Financial support and sponsorship: None.
4. Conflicts of interest: None.

References