Higher education methods have shifted from providing instruction to facilitating successful learning opportunities and engagement of the learner. Interactive simulation environments support learner-focused, constructivist approaches that would be unethical, inefficient, and unfeasible in actual perioperative care situations. Team training has a long history in aviation and the military, and, more recently, these experiences have been translated to health care. Studies of aviation teams reveal failures of coordination, communication, workload management, loss of group situation awareness, and inability to use available resources [5–7]. In thoroughly investigated adverse events, whether patient-or aviation-related, causes of failure were similarly multifactorial, team based, and complex [8–11].

Most of health care is performed and delivered by interdisciplinary teams – individuals with diverse specialized skills focused on a common task in a defined period of time and space, who must respond flexibly together to contingencies and share responsibility for patient outcomes. This is particularly true of cardiac surgery. Traditional specialty-centric clinical education and training are remiss because they assume that individuals acquire adequate competencies in teamwork passively without any formal training. Reviews of malpractice claims indicate that communication problems among the treating team members are major contributing factors in 24 % of cases that result in such claims [12]. Substantial evidence suggests that teams routinely outperform individuals and are required to succeed in today’s complex work arenas; in these settings information, wisdom, and resources are widely distributed, technology is becoming more complicated, and workload is increasing [13]. Other studies using root cause analysis to examine contributing factors have found teamwork and communication issues cited as root causes in 2/3 of adverse events [14]. Our understanding of how medical teams coordinate in real-life situations, especially during time-constrained and crises situations, remains incomplete.

Data from over 100 surgical root cause analysis (RCA) investigations demonstrated a number of themes that are relevant in understanding why and how surgical care can go wrong [14]. These themes (Table 5.4) represent a mixture of the outcomes of clinical care (e.g., procedural complications), and explanations relating to problems in the clinical environment (e.g., skill mix of the surgical team, and missed diagnoses).

Human factors research on team decision-making in complex task environments is of relevance to cardiac team performance. One must carefully consider the impact of the many “performance shaping factors” that can shape and degrade cardiac surgical outcomes (Table 5.5).

Assessing team performance is key to understanding methods to improve the team performance and increase the safety of patient outcomes (Table 5.6).

There is an ongoing argument in the literature that team process and outcomes must be distinguished [47]. Processes are defined by the activities, strategies, responses, and behaviors employed by the team during task accomplishment, while outcomes, are the clinical outcomes of the patients cared for by the team. Process measures are important for training when the purpose of performance measurement is to diagnose performance problems and to provide feedback to trainees. Until recently, the medical community has focused more on outcomes than on process measures. Medical educators have begun to appreciate the competencies that define effective team processes [48]. The key is to identify and measure processes that are directly related to patient outcomes (e.g., successful resuscitation). Perhaps most importantly, the results of the assessment must be translatable into specific feedback about technical or non-technical issues that can enhance the team’s performance in achieving a safe outcome [49].

There are a variety of methods to support the team’s reflection and evaluation of their team performance including debriefing with or without the use of videotaping, simulation with or without standardized patients, and the use of trained observers. Although metrics are available in nonmedical domains, there are few well-defined validated metrics to assess competency in complex clinical team activities such as resuscitation. No rigorous evaluation studies have been undertaken that relate the training experience with actual clinical outcomes thereby validating metrics for assessing team performance.

Simulations that use pre-scripted learner-focused scenarios not only ensure that relevant competencies are being assessed, but also ease the assessment process because instructors know when key events will occur [50]. Evaluation, both formative and summative, must provide a basis for diagnosing skill deficiencies. In other words, it is not enough that a simulation captures performance outcomes; it must also evaluate the process of moment-to-moment actions and reactions to help better design effective care.

There are substantial ethical and educational limitations to the use of patients for the clinical training of individuals and teams. The opportunities to learn and practice desired responses to uncommon events or types of injuries can be quite limited, even in a busy medical center. In fact, actual surgical resuscitations such as massive bleeding, air embolism and acute tamponade are not optimal training opportunities because patient care takes precedence over teaching. Meaningful learning occurs after events when there is time to reflect and review events of the care, and examine what worked well and what could have been improved. Moreover, many cardiac surgical emergencies occur in an uncontrolled environment under time pressure constraints. Societal and regulatory pressures will increasingly limit the use of real patients, especially critically ill ones, for hands-on clinical training. High-fidelity patient simulators allow educators to provide repeatable, controlled clinical scenarios, affording individuals and teams the freedom to fail without jeopardising patient health [58]. The simulation environment allows concurrent assessment of response processes while increasing competency training. Simulation training enables trainees to become proficient before treating patients [59]. The fidelity offered by simulators provides the best approximation of the novelty that may be encountered when performing other complicated clinical procedures in situ. Although access to simulation tools and approaches is rapidly expanding, there is no general agreement about what is optimal process, device specifications, metrics to evaluate curricula or their effectiveness, standardized performance measures, or validated protocols for training.

Inroads have recently been made in this area with the development of frameworks such as Non-Technical Skills for Surgeons (NoTSS) [60], Anaesthetic Non-Technical Skills (ANTS) [61], and Scrub Practitioners List of Intra-Operative Non-Technical Skills (SPLINTS), which allow a common taxonomy and framework with which to develop process measures in the teamwork domain within the operating suite environment, and which may carry over to other settings [62]. It is important to note that these are observational frameworks, designed to be used to measure observed behaviours in the operating room. They do not establish standards of performance, and are not specifically intended for use in a training environment, although may provide useful measures in some simulation scenarios.