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met with resistance. Like many physicians, I had prided myself on believing I
was competent (and I think I actually was competent…), and, again, like many
physicians, I was not overly keen to delve into human error in medicine and team
performance in healthcare. For many of us, that topic feels just a little too close
to home, at least at rst take. Rather, I focused most of my interest and efforts on
our work in aviation safety. I learned about CRM training, which by that time had
ceased to be a controversial topic in aviation and by then had become the standard
of practice for any good airline.
Rather than dening CRM and developing training programmes for aviation,
our lab’s efforts at that time were focused on in-ight data collection – trying to
understand what worked and what did not in the cockpit; on what practices the
good pilots demonstrated, and what we thought the rest should try and emulate.
These were the early days of LOSA – the Line Operations Safety Audit. The
University of Texas LOSA programme involved sending observers from our lab
group out onto aircraft ight decks to watch crews at work as they ew routine
ights, recording crew behaviours and errors, and noting their responses to safety
threats (Helmreich et al. 2002). Our experience was showing us that when LOSA
audits went ahead without management support, then resources were scarce and
the projects tended to stall. When senior management pushed for an audit, but the
pilots were mired in labour disputes or felt they were being used as scapegoats for
problems on the ight line, observers from our lab were greeted with suspicion in
the cockpit and again, safety audits stalled. When everyone in the organization was
on board, and when both senior management and pilot unions were enthusiastic
supporters of the safety audit, the process was typically a major success, and the
organizations would devour the ndings produced by the audit. There was a sense
that everything was moving forward as it should, and that we were all contributing
to something valuable.
I was fortunate to be a part of those efforts. We all had the sense we were doing
something worthwhile. Despite the difculties associated with research and the

challenges in producing empirical validation, few in our lab group or in commercial
aviation for that matter seemed to doubt the effectiveness of CRM, or the value of
trying to improve it. During this time, many of the rst efforts in trying to bring
CRM to healthcare were underway. David Gaba at Stanford had already started his
Anesthesia Crisis Resource Management training programme (Gaba et al. 1992),
which was receiving positive reviews in the safety community. Bob Helmreich
had been working with Swiss collaborators to bring CRM to operating room teams
in that country (Helmreich et al. 1994). MedTeams, a commercial training group
out of Boston, had produced a consulting and training product and had brought
their version of healthcare CRM to several sites in the United States (Morey et
al. 2002). By the late 1990s, Rhona Flin and colleagues in Scotland had started
work on the Anaesthesia Non-Technical Skills project, an empirically derived,
non-technical skills rating system (Fletcher et al. 2003) that remains one of the
stand-out efforts to date in our growing eld (see also Chapter 12 in this volume).
In the US, healthcare team training (or CRM, or non-technical skills programmes)
Putting Behavioural Markers to Work
425
is offered at a number of simulation centres, and such courses tend to be focused
on the operating room, the intensive care unit or cardiac arrest management.
Training is also offered through professional consulting organizations providing
a range of related leadership training, organizational assessment, culture change,
and team training services. Around 2003, Bob Helmreich and I wrote some of
our impressions and thoughts in a paper entitled ‘Team training and resource
management in healthcare: current issues and future directions’ (Musson and
Helmreich 2004). Details of these early programmes are described in that paper,
along with some worries about how things were proceeding. Our concern at that
time was primarily that CRM was becoming a private consulting project in many
quarters, and that the open, collaborative environment that fostered the growth
and success of CRM in aviation was almost nowhere to be found. Thankfully, this
is changing, as demonstrated by the behavioural markers researchers meeting in

Edinburgh, 2007 that was organized by Rhona Flin and that spawned this book.
However, there is still a nagging discomfort in the back of my mind that has been
present since I rst became aware of the potential promise of CRM to improve
healthcare delivery. That discomfort stems from the sense that there are fundamental
differences between healthcare and aviation, and that these differences stand to
undermine the many efforts underway that are trying to improve how teams work
in critical healthcare settings. This chapter, hopefully, articulates some of those
concerns and helps shed light on how some of us should proceed on this important,
though sometimes frustrating path.
CRM in Aviation
There is some value in briey revisiting what CRM really is in aviation. In that
industry, CRM has undergone a long evolution over the past 30 years – this has
been described elsewhere, and I will not belabour the chronology of increments
and evolutions in this chapter. As seen through the eyes of those in healthcare who
have looked to aviation for system improvement, CRM has been interpreted as
a set of skills that should be trained in order to improve teamwork and improve
safety. In a sense this is true, though some key points seem to have been lost
in transition. CRM is as much an organizational philosophy as it is a training
programme. I was not around in the earliest days, but if I had to guess, I would
imagine that this has not always been the case. CRM started as a means of training
better cockpit leadership skills, but soon became integrated with human factors
training in general – a more comprehensive training movement that dealt with
the risks posed by the ways humans operate in complex settings. For example,
good CRM courses include didactic teaching or small group workshops that focus
on such things as the effects of fatigue on concentration, memory and decision-
making; curricula include discussions on how family stressors can serve as
distractions and how telling your crewmates of such stressors helps alert everyone
to the potential impact of those stressors in the cockpit on that day. Such material
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serves not only to add to the base of knowledge essential for understanding how
good CRM works, it also serves to shift attitudes among trainees from one of
autonomous independence to one of team-centred interdependence. The concept
of safety as an underlying fundamental (or super-ordinate) goal that serves to unify
team members’ motivations and behaviours is stressed as a fundamental principle
of crew management.
Over time, as new pilots are indoctrinated into CRM and adopt its principles
of crew management and as the majority of pilots in various airlines adopt a team-
centred approach to daily operations, the principles expounded by CRM seem to
have permeated the senior ranks of commercial aviation and the very culture of
ight operations. This is not surprising, as senior pilots tend to ll both middle and
upper management positions at most airlines. It is not uncommon to hear pilots
describe management’s actions and decisions in terms of ‘good CRM’ or ‘bad
CRM’.
All that is CRM, of course, has taken root in the pre-existing operating
environments of aviation and over the pre-existing cultures of piloting. Cockpits
are small, both in terms of space and in terms of crew numbers – always at least two
in number (in commercial aircraft, at least), and seldom more than three. Everyone
in the cockpit has essentially the same training, often very common backgrounds,
and even similar personality types. Pilots did their jobs very well before CRM
ever came along, and in that light, CRM can be thought of as the icing on the
cake of high-level team performance. CRM provided a framework to help highly
functioning teams become even better. The infrequent mishaps that had occurred
in aviation in the years prior to the introduction of CRM, where miscommunication
between or intimidation of crew members contributed to mishaps, became even
less common thanks to improved awareness of human factors and to the skills
introduced into crew training through CRM. It is important to remember that CRM
was never brought in at the expense of existing good practices. What we used to
call good ‘airmanship’ has been expanded to include the fundamental elements
and principles of CRM, and the culture has undergone a re-conceptualization

of piloting competency that integrates both technical prociency and CRM as
essential skill sets.
CRM in Medicine
As mentioned above, a number of individuals began looking at developing CRM,
or non-technical skills training programs for healthcare in the 1990s. In 1999, the
Institute of Medicine (IOM) released its report To Err is Human: Building a Safer
Health System (Kohn et al. 2000). In it, aviation-based CRM was identied as a
key strategy that held great promise for reducing error in the complex treatment
teams that are ubiquitous in modern healthcare. This triggered immediate interest
in CRM and the activities of our lab in Texas, and set in motion a growing interest
in the subject that has only gotten stronger with time.
Putting Behavioural Markers to Work
427
But, as I mentioned at the opening of this chapter, I have had a nagging feeling
that CRM was not quite the answer that many thought. The parallels between the
operating room and the cockpit seemed obvious to many and to me as well, but
I thought that there seemed as many differences as similarities. Compared to the
civilized two-person teams I had seen in cockpits, the operating room had always
felt like a jungle to me. People came and went throughout each operation. As a
medical student and intern, I never knew the identities of at least half of the masked
people in the room, and I was never sure if anyone could actually name each person
who came and went. Maybe the circulating nurse knew who they were, but I sure
didn’t. Sometimes, she would switch out mid-procedure when her shift ended, and
a new person (whose identity was also unknown to me) would come into the room
to take her place without a word being spoken. At times the atmosphere was casual
and light-hearted, at other times it was tense and sometimes hostile. Instruments
do get thrown – that is not an urban legend; I have seen it happen on more than one
occasion. More often, insults were thrown, usually directed to residents or interns,
though also at times they would be cast at entire groups (non-surgical specialties
were a frequent target). Eyebrows were used to communicate disapproval and

irritation, and could be used to do so quite effectively. The humour was at times
bawdy, and as the lowly medical student you were not always quite sure when you
should laugh and when you should remain quiet. It was always safer to just hold
the retractor as instructed, though one could never go wrong nodding in silent
agreement with whoever was most senior. Production pressure was paramount.
Anything that delayed the completion of the case had the potential to upset the
rest of the day’s list and a number of people in the room. Everyone seemed to
have their own job; there was seldom any sharing of tasks and there seemed little
awareness about what others’ jobs entailed. The ether screen, suspended between
two poles on either side of the patient’s head, served to separate the world of
surgery from the world of anaesthesia. Sometimes it seemed higher than it needed
to be. Maybe it was to protect against ying instruments, I wondered. As a doctor
in training, I knew virtually nothing of the world of nurses, except that in the
operating room they seemed efcient and key to everything that transpired, though
they were typically silent. This was my impression of surgical operating teams,
and to me, introducing CRM skills like brieng and cross-checking would not
necessarily make things run all that much better. The idea that CRM would x
everything I had seen in training and later in practice seemed a tall order.
Undaunted by the challenge and motivated by a sincere desire to make
healthcare safer, a number of parties have forged onward in their attempts to
improve the performance of operating room teams, and of teams elsewhere in
healthcare through the development and implementation of CRM-like training.
At the time of writing this chapter, I have since moved on from Bob Helmreich’s
group (and he has retired) and I now oversee simulation and non-technical skills at
McMaster University. As such, I nd myself dealing with the front line issues of
integrating CRM or non-technical skills into the postgraduate medical curriculum
at our university, and with integrating simulation and patient safety into a
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428
number of undergraduate programmes. Indeed, simulation is by many accounts

a valuable tool in our arsenal as we look for the best ways to improve healthcare
team behaviour. There are many challenges, such as how we rst introduce these
concepts and at what level. Or, how we educate the practising provider population
so that our trainees do not meet resistance to using their new-found skills as they
move on from our educational programmes and into the day-to-day working
environment of healthcare? I, like others, am grateful for the work of our Scottish
colleagues who have developed the ANTS methodologies, and the more recent
Non-Technical Skills for Surgeons (NOTSS) system that you will nd described
elsewhere in this book (see Chapter 2). I remain convinced that these programmes
are on the right track and should be integrated into any efforts to improve operating
room team performance.
There are a number of us struggling with these same challenges of how
best to design, deliver and evaluate CRM or non-technical skills training for
healthcare. Many efforts in this area have stalled, or have produced less radical
change in the day-to-day behaviour of operating room teams than some had hoped.
Anecdotally, it is common to hear frustrations from those who have attempted
to implement such programmes. Beginning with early programmes, such as
MedTeams, and progressing to the current day, trainers and course developers
lament the difculty of getting the simplest of interventions to be adopted, though
often these frustrations are voiced in private since many of these efforts involve
either commercial consulting groups or academic centres where project failure is
not well regarded. Efforts to bring team skills training to healthcare are resource
intensive and expensive. When clinical champions and institutional leaders have
fought hard to bring in expensive training programmes into their local institutions,
challenges are not usually discussed openly and outright failures are sometimes
denied.
So, why does this training sometimes seem less successful than we would like?
Why is there resistance among highly competent professionals to adopt practices
that we think make perfect sense? Presumably these individuals are interested
in delivering quality care, regardless of what other competing demands may

be present. Aviation had its difculties and challenges for sure, but either the
challenges in healthcare are greater or the standard for success is higher. Possibly
both are factors. The threshold for determining success in healthcare is frankly
more rigorous than it ever was for aviation. Decision-makers want hard evidence
of success before scant resources are directed towards CRM and team training
courses. A poorly known (and seldom communicated) fact of aviation safety is
that evidence for the success of CRM has actually been quite elusive. Eduardo
Salas at the University of Central Florida has written extensively and thoroughly
on issues related to the validation of CRM training, and in particular on the
challenges of validating such training in the complex operational environments of
healthcare and aviation (for detailed reviews of CRM evaluation, see Salas et al.
1999, 2006). In this chapter, however, we will assume that improving teamwork,
sharing expectations associated with the task at hand, informing others of one’s
Putting Behavioural Markers to Work
429
plans, improving communication in general, task redundancy, reducing needless
variability and having team members monitor each other to improve reliability are
all good things, and that programmes to encourage these behaviours should have
at least some positive benet on team performance in healthcare.
In this chapter, I want to examine what it is that seems to be standing in the
way of many sincere and diligent efforts to improve team performance. Take the
example of the ‘surgical time out’ or ‘surgical pause’ (WHO 2008). This is the
practice of ensuring everyone is present at the start of a surgical case, where the
identity of the patient is conrmed, along with the site of surgery and conrmation
of the specic nature of the procedure. This was introduced to prevent wrong-
site, wrong-patient surgical errors. It can also serve as a tool to communicate
expectations between team members, brief potential contingencies and possible
complications, and provide an opportunity to clarify everyone’s mental model of
what is about to transpire. This is what those of us in aviation safety would call
‘basic CRM’, and is an example of how we would get team members to ‘share

their mental model’ amongst each other. It is current best practice for surgical
care, and in North America is encouraged or required by agencies such as the
Joint Commission, the Institute for Healthcare Improvement (IHI), and the
Canadian Patient Safety Institute. To most of us in the error/CRM/non-technical
skills world, the value of the surgical time out is obvious, and any downsides are
almost impossible to identify. Yet, accounts of difculties in implementing this
simplest of practices abound. Some surgeons refuse to do it, others roll their eyes,
while yet others are reported to ridicule the resident or nurse who reminds them
that the practice be followed. In other centres, certainly, the practice is adopted
and enthusiastically supported. The question remains, why the difference and
why would anyone resist? It is a simple behaviour. The theoretical basis for it is
strong. The amount of effort is minimal. Is it because it is being forced, and anti-
authoritarian tendencies cause some to rebel? Is it seen as a loss of professional
autonomy? Do they not believe that it makes any sense? Is there a perceived loss
of efciency in the operating room? Surely, if such a simple practice meets with
resistance, more complex and less concrete practices are also doomed, at least in
some settings.
Let’s start with the basics. CRM, or non-technical skills programmes, involve
the process of describing the behaviours of highly competent, safe individuals.
A current approach in healthcare is to develop a comprehensive list of such
behaviours and develop a training programme around that list. Surely ANTS and
NOTSS are excellent examples. Those systems have been empirically derived,
agreed upon by a consensus of experienced practitioners, and the face validity of
their component elements is strong. Good training programmes may also involve a
signicant amount of supporting theory, didactically delivered and well founded in
psychology and experience. Some programmes even involve signicant coaching
with ongoing reinforcement. Yet the desired behavioural changes in team members
have not been consistently observed following training and even in well-designed
programmes, resistance is not uncommon.
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430
There are certainly examples of poorly run training programmes, some lasting
only an afternoon, without opportunity to practise skills or provide feedback, and
without a plan for reinforcement over time. Some programmes are simply copies
of aviation programmes, with little domain specicity, and we would not expect
such programmes to result in major changes in team behaviour. But, some courses
seem extremely well designed, and much effort has gone into their delivery and
implementation. Yet, still, many of these programmes have failed to produce the
desired outcomes.
Are we right to be focusing on behaviours? The term in our eld is behavioural
markers, and it refers to the explicit, observable actions of team members. Our
thinking to date has largely been to identify the optimal behaviour set employed
by ideal practitioners, usually arrived at through consensus methods, and teach
everyone to practise those same behaviours. Seems straightforward. But, what are
human behaviours? Why do people behave the way they do? Why do good team
players naturally share their plans with their team members, even without being
told to do so? Why do some people resist changes even when they seem to make
sense? If we think of behaviour as stemming from our cognition – action from
thought, as some would say – then the question becomes: what are they thinking
and why? If we are going to change the way people behave in the operating room,
or elsewhere in healthcare for that matter, we need to be examining why they do
what they do.
Behind the observable behaviours of an individual lie the various processes
of human cognition. This includes all of the things that inuence our moment-
to-moment and day-to-day thinking, working away in our minds, often below the
surface and out of sight: our values, attitudes, perceived responsibilities, memories,
and even our own personality characteristic tendencies. Furthermore, we can ask
what has led us to have those attitudes and beliefs. In our work settings, this may
be the professional cultures into which we have been acculturated, or the many
interactions we have had with others over our careers, or even the national and

organizational cultures that surround us at home and work. All of these factors
inuence who we are and how we think. You can picture an iceberg, with the
base being the social structures, cultural backgrounds and organizational milieu
in which we live lying deeply below the surface of the water. Examples of these
deep-seated inuences may include pre-existing social attitudes about gender
and roles, or more concrete factors like the lounge that allows surgeons, but not
nurses, to relax and make telephone calls between cases and the messages that
this gives us. These factors serve as the foundation for the middle layer, which
lies just below the surface: our day-to-day thinking; the attitudes, values and
cognitive processes. The top of the iceberg, rising above the surface, represents
our observable behaviours; the only thing others can see from the outside. I have
drawn this below in Figure 25.1.
This chapter is about behavioural markers, training and learning from aviation,
so let’s go back to aviation for a minute. CRM had its challenges, to be sure, but
the healthcare experience, I believe, is proving more problematic and the road
Putting Behavioural Markers to Work
431
more uneven. Why did CRM seem to work more easily in aviation, or at least why
is it more readily accepted now? If we examine the nature of aviation teams, what
do we nd? Captains and rst ofcers, as I have mentioned, are similar – similar
backgrounds (ight school), similar interests (airplanes), similar frustrations (Air
Trafc Control), and even similar haircuts. They share their jobs – often alternating
who is in command and who is monitoring on each successive ight. There is
little confusion about the goal – a smooth ight and safe landing. The only major
barriers to communication are usually hierarchy, experience and sometimes a
tendency to work as an individual and not as a team. CRM was designed to address
these barriers; hence, much of its focus is on overcoming hierarchical barriers to
communication, sharing plans for the purpose of mutual understanding and the
importance of coordinating tasks in cockpit crews.
An important question to ask is this: do surgical teams encounter the same

challenges as those encountered by pilots? By this I am not referring to ap
settings vs. intubation difculties; obviously the technical challenges are different.
But, are the barriers to the uid ow of information due to the same issues of
command hierarchy? Sometimes, perhaps, but is this always the case? Are there
other barriers? Interprofessional friction, for example? Is there a perception
that the job of the anaesthesiologist is separate from that of the surgeon? Do
surgeons, anaesthesiologists and operating room nurses have similar personalities,
similar experiences and identical goals? Professional subgroups, or occupational
Figure 25.1 An iceberg model for observed behaviours
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432
subcultures as some call them, are everywhere in healthcare. Doctors, nurses,
medical sub-specialists, technicians and therapists – all see themselves as groups
distinct from each other. They relax in different lounges, use language and jargon
specic to their subgroups, and wear trappings and symbols of their group
membership. There are hierarchical barriers within disciplines (residents/registrars
and consultants) and between disciplines (who is in charge in the operating room:
anaesthesia or surgery? Asking this can start a brawl…) and of course, between
professions (doctors, nurses and others).
Each sub-group or discipline has its own perceived strengths and roles. Some
see themselves as doing the primary job at hand (such as surgery), while others
may see themselves as risk mitigators (such as anaesthesia). Each believes they
are doing their job to the best of their ability; the surgeons are typically technically
competent, the anaesthesiologists maintain stability of the patient, the nurses
ensure order in the room, produce equipment for the surgeon as needed without
delay and count sponges to make certain nothing is left behind. Friction between
sub-groups and sub-cultures is common. Humour may be directed at one group or
another, and disparaging generalizations about one profession or another, or about
one specialty or another are not rare.
If we return to our iceberg diagram, we can picture a schism or a fault in the

base – a rift between groups, or dysfunctional professional cultures. The problem
may be specic to one team, or characteristic of a given culture in an entire
hospital or teaching centre. It may be the doctors-only lounge that was mentioned
earlier. This fault in the foundation of team structure leads to dysfunctional
attitudes, biases and differing values within those teams, and eventually manifests
as poor team behaviours – perhaps a tendency toward individualistic behaviour
or a reluctance to help out with heavy workload. An example of such behaviour
would be a reluctance to ask for help with a busy taskload, either because mutual
support is not part of the culture, or because a practitioner could be self-conscious
about appearing to not be able to cope with his or her workload. A particular work
setting may well evolve its own xes and informal countermeasures to deal with
perceived risks to safety or deciencies in team performance. These may take the
shape of unofcial rules, or things nurses do without the physicians’ awareness
to try and ensure safety and quality. The visible behaviours resulting from deep-
seated fractures within the team structure can be more egregious: insults, disrespect
or open hostility.
Anecdotes of team dysfunction are rampant in healthcare, though systematic
analysis is seldom found in the literature. These are stories shared in the nurses’ or
residents’ lounges or over drinks with colleagues on a Friday night. Few of us would
expect that CRM training or non-technical skills courses would likely eradicate
these problems, and resistance to change can come from either a perception that
the new skills offered will undermine existing practices, or because the underlying
team structure is so dysfunctional that no brief training programme is likely to
repair the existing degree of damage.
Putting Behavioural Markers to Work
433
So, back to aviation. Is there anything that the aviation industry can teach
us about how to implement changes in team behaviour? Our experience with
LOSA, as you might remember from earlier in this chapter, was that without
both senior management and workforce buy-in, our efforts often proved futile.

In healthcare, this would mean getting senior administrative personnel to support
team improvement efforts (specically, the chief executive ofcer, the chief of
medical staff and the chief nursing ofcer, at a minimum), and in the case of
the operating room, the heads of surgery, anaesthesia and nursing. Why is this
important? Without the support of the senior executive of an organization,
resources will not be adequate and those trying to implement change will nd
institutional resistance acting as a major barrier to their efforts. It strikes me that I
have not dened ‘support’. By support, I mean money (which is rare), not a letter
of support (which is more common). These projects require resources. They may
require operating rooms to close for training, which means loss of revenue. Senior
management in one institution may choose to pay staff to attend training, while in
other institutions they may be expected to attend on their own time. Without buy-
in from key physicians and nurses, medical and nursing staff are unlikely to role
model and encourage the proposed changes, and desired behaviours and practices
will likely disappear after training, despite best intentions.
Our experiences in healthcare CRM, however, suggest that top-level and
practitioner support alone is not likely to be enough. Many of us in this eld often
say that healthcare is more complex than aviation, but what does that mean? This
belief really relates to the nature of our work groups more than it does to the actual
work itself. Teams in healthcare are unstable; their members come and go through
the course of the week, the day and even the procedure. Multiple professions and
disciplines, as discussed above, must work together, and often must deal with
unusual stresses and sources of friction. It is no secret that in many institutions,
bad behaviour on the part of some senior staff is tolerated. The growing numbers
of formal codes of conduct currently appearing in our hospitals attest to this
fact, as institutions try to nd administrative tools to deal with the problem of
disrespectful and offensive behaviour. Such issues must be dealt with if any attempt
to improve team performance is going to succeed. Our experience in aviation was
that disruptive and abusive pilots were strong resistors of CRM and actively tried
to subvert those programmes when they rst appeared.

Will CRM or Non-Technical Skills Training Work in Healthcare?
There is probably little doubt that in well-functioning operating rooms teams
(and for teams elsewhere in healthcare), CRM and non-technical skills training
can raise reliability and safety to a higher level. The important question is how
do we go about implementing this, or what else needs be done? Paul Uhlig,
another participant at the Edinburgh meeting in 2007 and contributor to this book
(see Chapter 26), has written and spoken extensively about the need to reform