The Journal of Continuing Education in Nursing

Original Article 

Development of a Virtual Crew Resource Management Training Program to Improve Communication

Dana Tschannen, PhD, RN


Crew Resource Management (CRM), a method focused on the management of human error and risk reduction, has shown promise in reducing communication failure in health care. The purpose of this project was to develop a virtual training program in CRM principles of effective leadership and followership, and evaluate the applicability to nurses working in the hospital setting. The intervention included the development of a virtual CRM training program consisting of a self-learning module and virtual simulation. Beta testing of the module was conducted by six nurses, followed by an evaluation of the training program by nurses (n = 5) in a general medicine department. Nurses reported the overall program to be worthwhile (= 5; SD = 0.5), with great applicability to nursing care (= 4.5, SD = 0.5). Nurses completing the simulation activity reported strong agreement to CRM applicability and training effectiveness. The CRM training module proved to be applicable to nursing care and is ready for widespread use to improve patient care and communication.

J Contin Educ Nurs. 2017;48(11):525–532.


Crew Resource Management (CRM), a method focused on the management of human error and risk reduction, has shown promise in reducing communication failure in health care. The purpose of this project was to develop a virtual training program in CRM principles of effective leadership and followership, and evaluate the applicability to nurses working in the hospital setting. The intervention included the development of a virtual CRM training program consisting of a self-learning module and virtual simulation. Beta testing of the module was conducted by six nurses, followed by an evaluation of the training program by nurses (n = 5) in a general medicine department. Nurses reported the overall program to be worthwhile (= 5; SD = 0.5), with great applicability to nursing care (= 4.5, SD = 0.5). Nurses completing the simulation activity reported strong agreement to CRM applicability and training effectiveness. The CRM training module proved to be applicable to nursing care and is ready for widespread use to improve patient care and communication.

J Contin Educ Nurs. 2017;48(11):525–532.

One of the most critical aspects in providing high-quality care is effective communication. Communication failures among the health care team remain a primary root cause reported to The Joint Commission (2004 to 2014) for the most commonly reviewed sentinel events: unintended retention of foreign object, wrong patient, wrong site, wrong procedure, falls, and delay in treatment (The Joint Commission, 2015c). Interventions recommended for improving communication—and minimizing sentinel events—include postincident huddles, standardized handoffs, promotion of provider communication, and team briefings and debriefings (The Joint Commission, 2013, 2015a, 2015b). Such tools are included in Crew Resource Management (CRM) training (e.g., Medical Team Training), a training method focused on risk reduction and management of human error (Sculli, Fore, Neily, Mills, & Sine, 2011). CRM involves the identification and communication of threats to an operation by crew members to a person in charge, followed by the development, communication, and implementation of plans to mitigate or avoid the threat (Tschannen, McClish, Aebersold, & Rohde, 2015). Concepts in the CRM program include leadership and followership, situational awareness, assertive communication strategies, human factors issues, and checklists. The Joint Commission (2013) reports CRM as being “effective in promoting assertiveness and overcoming hierarchical barriers to communication” (p. 3).

One challenge with CRM training, similar to other team training programs, is the current training modality, which primarily consists of resource-intensive, in-person training. This is despite wide availability of Web-based learning options. Online learning pedagogy holds much promise in reducing cost and increasing flexibility and wide dissemination of training. However, it has not been well used or tested for training. For this reason, the purpose of this pilot project was to expound on previous work by developing a virtual training program in CRM principles of effective leadership and followership, and evaluating the applicability of the training to nurses in the hospital setting.

Literature Review

Team training, such as CRM, has been identified as an effective strategy for improving patient safety. O'Dea, O'Connor, and Keogh (2014) conducted a meta-analysis to determine the effects of CRM training. CRM training was found to have a large positive effect on participants' knowledge and behaviors, with an additional small effect on attitudes. Pettker et al. (2011) reported a significant improvement in perceptions of teamwork (24% improvement), safety culture (30% improvement), job satisfaction (14% improvement), and management (27% improvement) among nurses and physicians within an obstetrics service after a CRM intervention. Similarly, Sculli et al. (2013) implemented nursing CRM training in 11 departments within the Veterans Affairs Health System and found a 14% increase in perceptions of nurse teamwork and morale, with 98% (n = 685) of participants agreeing or strongly agreeing that they developed new skills and knowledge useful in the work setting.

Improvements in patient safety behaviors, such as closed loop communication, team briefings, and huddles, also has been reported post-CRM training. While evaluating the effects of CRM training at four emergency departments, Noord, de Bruijne, Twisk, van Dyck, and Wagner (2015) noted a 25% increase in professional oral communication among nurses and physicians posttraining. After a checklist with prebrief (e.g., a huddle) and debrief components during a delivery were instituted in one neonatal intensive care department, communication issues were reported less often from the first (23%) to the last (4%) time period (p <.001) (Katheria, Rich, & Finer, 2013). Similarly, Paull et al. (2010) implemented a briefing and debriefing in the operative suite after the medical team training of more than 12,000 health care providers. Patient safety interventions, which included antibiotic and deep vein thrombosis prophylaxis compliance rates, improved during the 12 months posttraining compared with the 12 months prior to training.

Several studies have identified a significant relationship between CRM training and quality and safety outcomes, including patient mortality, operating room efficiencies (e.g., delays, handoffs), and medication error rates (Fore, Sculli, Albee, & Neily, 2013; Neily et al., 2010). After a system-wide roll out of CRM training (N = 3,600 health system employees in 12 areas) in one midwestern U.S. health system, the number of avoided adverse events was 735, resulting in a 25.7% reduction in observed, relative to expected, events. In addition, the cost savings over 3 years ranged from $12.6 to $28 million, with a return on investment of $9.1 to $24.4 million (Moffatt-Bruce et al., 2017). In a 3-year cohort study in the intensive care department, Haerkens et al. (2015) reported a significant decrease in complication rate pretraining (67.1 of 1,000 patients) to posttraining (50.9 of 1,000 patients), with a corresponding decrease in mortality odds (pretraining odds ratio [OR] = 0.72 to posttraining OR = 0.60). In addition, the incidence of cardiac arrests decreased, with cardiac resuscitation success rates increasing from 19% to 67%.

Despite the success of CRM training, several barriers to implementation of the proven team training exist. The incongruent workflows among the interprofessional team and 24-hour demand for patient care makes it difficult to coordinate team training. Staff shortages, location accessibility, and training delivery modalities add to the difficulty of conducting a successful training program (Ward & Wood, 2000). In an effort to circumvent some of these barriers, Clay-Williams, Greenfield, Stone, and Braithwaite (2014) developed a modular format for CRM training and tested it in one tertiary hospital. Health care staff (N = 23) from medicine, nursing, midwifery, and allied health completed one or both of the developed face-to-face modules. Learners found the communication module to be most useful, although more practice in using the communication tools was suggested. The modular format provided greater flexibility for attendance and was aligned with results from other full-day, face-to-face trainings; yet, the difficulty of attending face-to-face training remains a barrier.

Previous studies by the author of the current study aimed at improving communication using CRM principles noted similar barriers to maximum training effectiveness. Nursing students in a baccalaureate program received CRM training in a 6-hour didactic session, which was followed by a standardized simulation (Aebersold, Tschannen, & Sculli, 2013). Students and faculty found the training to be applicable to practice ( = 4.7; SD = 0.46) and rated the experiences very highly ( = 4.5; SD = 0.56). The training was possible because it was part of the students' scheduled clinical day, but scalability of the training was limited due to the time requirement and learning modality (e.g., face-to-face). The second phase of work involved implementing CRM training into a general medicine unit (Tschannen et al., 2015). The training consisted of three 20-minute in-service sessions that were conducted over 6 weeks. The original target audience was both nurses and physicians in the department, although only nurses were able to attend the in-service sessions, despite offering each session four times. Although communication improved on the unit, it was clear that greater influence could be obtained with full participation from the interdisciplinary team. Standard, didactic, face-to-face training sessions did not allow for the versatility needed to effectively reach the full interpersonal team. For this reason, use of virtual modalities was explored.

CRM Training Development

A virtual training program engaged learners in an online activity focused on CRM principles of effective leadership and followership. The competency for the CRM module was for learners to implement effective leadership and followership strategies in the health care environment to optimize patient outcome and care processes. Critical behaviors were identified for both effective leadership and effective followership (Table 1). The CRM training program consisted of two components: (a) a self-learning module and (b) virtual simulation training. Details for the development of each training component follows.

CRM Training Competency and Critical Behaviors

Table 1:

CRM Training Competency and Critical Behaviors

CRM Self-Learning Module

The self-learning module presented the CRM principles of effective leadership and followership. Content specific to effective leaders included types of leaders (e.g., high- versus low-task and concern leadership), leadership skills (e.g., inviting participation, engaging the team, asking questions), closed loop communication, huddles, debriefings, and checklists. Effective followership content included types of followers, hint and hope communication, and the effective followership algorithm, which provides specific communication strategies for relaying critical information to the health care team. For example, the algorithm includes the three Ws (What I see, What I am concerned about, and What I want) (Sculli & Sine, 2011). It provides a succinct way for health care providers to state their concerns and needs regarding a critical patient situation.

The module included narrated slides describing the CRM content, followed by video vignettes depicting effective or ineffective use of the principles. Table 2 provides an overview of the CRM content and embedded video vignettes. The narrated slides were developed by the author of the current study and an expert consultant in CRM. Each didactic section was limited in length, in an effort to maintain learner attention and focus. Small segments of content were recorded using Camtasia©. This software allowed for easy recording and subsequent editing of narrated PowerPoint® slides without the need for highly technical skills from the developer.

CRM Module Principles and Video Vignette Overviews

Table 2:

CRM Module Principles and Video Vignette Overviews

The video vignettes were created using a previously developed five-step process for simulation development: (a) key concept identification, (b) competency mapping (e.g., link of content to CRM principles), (c) scenario building, (d) debriefing development, and (e) beta testing and refinement (Tschannen, Aebersold, McLaughlin, Bowen, & Fairchild, 2012). A formalized beta test of the scenarios did not occur during the development phase, rather clinical experts reviewed the scripts prior to filming to assure fidelity and realism with clinical practice. Funding provided financial support for an external film crew to conduct all filming and editing of the vignettes. The CRM training materials—including all narrated slides and video vignettes—were uploaded to a learning management system for dissemination. In addition, the module included “test yourself” sections, where learners needed to correctly identify responses that assured understanding of the material (e.g., “Identify the necessary components of a debriefing.”) before being able to continue with the module content.

CRM Simulation

The second component of the CRM training included an opportunity for practicing the use of the CRM tools through a simulation experience. This included a brief re-cap of the CRM key principles, followed by participation in two simulation scenarios. The same simulation development process as described above was used. The first scenario—describing a deteriorating patient experience— required learners to use the effective followership algorithm, which is a tool for health care providers to use when an escalation in communication is needed (Sculli & Sine, 2011). The provider response to the nurse's concern for the patient was deliberately scripted to require the nurse to escalate his or her communication techniques (e.g., use of the three Ws and a 4-step assertive tool that includes [a] get their attention, [b] state concern, [c] offer a solution, and [d] pose a question). The second scenario, which included an overview of simulated patients being cared for by a nursing team (e.g., two nurses, unlicensed assistive personnel), required the learner to conduct a huddle. A huddle checklist was provided to the learner, as well as an overview of each of the patients in the department.

Each simulation was followed by a debrief, asking learners for their perceptions of what went well, what they would have done differently, and the applicability of the CRM tools to clinical practice. These scenarios were chosen due to their applicability to all learners, regardless of area of specialty. The simulation training was developed to be implemented in the virtual training environment of Second Life® (SL), a multiuser virtual environment that has been used successfully in health training for years (Boulos, Hetherington, & Wheeler, 2007). SL allows for exploration, role-play, and user interactions through the use of avatars, an online representation of self in the virtual world (Peterson, 2005).

Beta Testing of the CRM Module. Initial testing of the CRM module was conducted with a small, convenience sample of nurses to ensure clarity in content and delivery method. Nurses were known to the investigator as fellow nursing faculty (n = 3), students (n = 1), or staff nurses (n = 2) at an affiliated institution. Experience levels of the nurses who completed the beta testing ranged from 3 to 30 years, with an average of 12.8 years of experience. All of the nurses reviewed the module, including completion of the pre- and postknowledge tests that accompanied the module. Nurses were asked to complete the intervention to determine the amount of time required for successful completion of the module, as well as to provide feedback on the module delivery mode and relevance to practice.

The average time required to complete the self-learning module was 76.8 minutes, with a range of 40 to 90 minutes. When asked to provide overall feedback regarding the module, nurses unanimously agreed the module provided information valuable to the practicing nurse, as noted in the following comment:

It clearly outlines how to be an effective leader and follower, both roles in which a nurse participates in the medical team. I think it showed clearly how to implement this into my own practice, and I am excited to try the new strategies in my daily work.

Feedback regarding the delivery modality within the module also was well received:

I really liked the module overall; the videos were very well done and showed good examples of how to use some of the CRM tools…. The module is excellent! It kept my attention with the combination of presentation slides and video examples…. The videos are so well done and clearly illustrate the teaching points in true-to-practice situations.

In addition, the nurses did note some revisions to the module, specifically regarding audio quality and editorial corrections. Based on the feedback, slight revisions were made to the module prior to conducting further evaluation.

Evaluation of the CRM Training

After making revisions to the module—based on the beta test—nurses on one general care department within the hospital setting were asked about their willingness to complete the CRM training for further evaluation of the module. Rationale for further testing was to ensure relevancy to nurses working in the clinical setting, as the beta testing was primarily conducted with nurses in the academic environment. The project was reviewed by the hospital institutional review board and deemed exempt.

Recruitment of nurses for further evaluation occurred through solicitation via an e-mail message and placement of flyers on a general medicine department. Five staff nurses responded to the message, stating their willingness to participate. The researcher followed up with each of the nurses and provided instructions for how to access the self-learning module, which was uploaded to the health system learning management system. All nurses participating in the module obtained continuing education credits in alignment with the time denoted for the activity. On completion of the self-learning module, the participants were asked if they would be willing to complete the simulation component of the training. Two nurses agreed, and a time was scheduled for the activity, which took place in a quiet office in the department 2 weeks after module review.

Evaluation Method

After each component of the CRM training, learners were asked to complete an evaluation. The self-learning module consisted of a pre- and postknowledge test on communication techniques. The tests included 10 multiple-choice questions with both knowledge-based (e.g., “When should the leader of the team hold a briefing?”) and scenario-based questions (e.g., “You are in Mr. Smith's room taking vitals when you see that his blood pressure and heart rate are abnormally high. Which of the following statements best communicates the information in a direct and concise manner?”). The pretest consisted of six knowledge- and four application-type questions, with the posttest including three knowledge- and seven application-type questions. Formalized testing of the items did not occur, although each item was reviewed by the beta test group for relevancy, clarity, and alignment with CRM content.

To evaluate the effectiveness and applicability of the CRM training to nursing care, a posttraining survey was given to the learners for both the module and simulation training. The survey—previously used by the developer— consisted of seven items on a 5-point Likert scale, ranging from 1 = strongly disagree to 5 = strongly agree (Aebersold et al., 2013). Questions asked learners to evaluate the training content, teaching strategies, and applicability to nursing care. In addition, two open-ended questions were included concerning the postsimulation training, asking learners to identify the most and least beneficial aspects of the simulation experience.

Evaluation Results

A total of five staff nurses completed the self-learning module, with two of these nurses completing the simulation training. Preknowledge scores were, on average, 74% (SD = 1.8), with a range of 50% to 90%. Postknowledge scores improved to 94%, on average (SD = 0.9), with a range of 80% to 100%. On review of the survey evaluating the effectiveness and applicability of the CRM training to nursing care, nurses noted the CRM training to be worthwhile ( = 4.5; SD = 0.5) and have great applicability to nursing care ( = 4.5; SD = 0.5). They reported developing new skills and knowledge ( = 4.3; SD = 0.4) that would subsequently be used in their clinical practice ( = 4.0; SD = 0.7). The teaching strategies also were well received, as noted by an average score of 4.3 (SD = 0.4). Nurses recommended the training to others and had interest in further training ( = 4.0; SD = 1.2).

Nurses completing the simulation activity also completed the survey evaluating the effectiveness and applicability of the CRM training. Both nurses completing the simulation training strongly agreed the training was applicable to practice and worthwhile ( = 5.0; SD = 0 [for both items], respectively). New skills were developed as a result of their participation in the simulation ( = 4.5; SD = 0.7) that they believed would be used in their clinical practice ( = 5.0; SD = 0). They enjoyed simulation as a teaching strategy and highly recommended the training for other clinicians and further training for themselves ( = 5.0; SD = 0 [for all items]). Additional comments on the survey included, “excellent interaction and engagement” and “scenarios related well to our patient population.”


The purpose of this project was to develop a virtual training in CRM principles of effective leadership and followership, and evaluate the applicability to nurses working in the hospital setting. The CRM training consisted of content regarding the CRM leadership and followership behaviors, as well as specific strategies and tools for improving communication among the interdisciplinary team. A virtual training modality was used in an effort to minimize some of the previous barriers to widespread dissemination of training in the health care setting (Ward & Wood, 2000). The CRM module included narrated slides and video vignettes depicting the CRM principles in a way to engage learners and maximize understanding for those with different learning styles.

The CRM self-learning module was reviewed by a small sample of nurses in the academic and clinical care setting during two phases of evaluation. In the beta testing phase, all learners related high levels of satisfaction with the teaching and the usefulness of the content to practice. The entire CRM training—including the module and simulation activity—was subsequently evaluated by nurses providing direct patient care in one general care department. Knowledge associated with effective communication and CRM principles improved 20% from preto post-CRM training. Nurses agreed the CRM training was worthwhile, resulted in the development of new skills, and was applicable to their practice. This finding is in line with other studies that noted an improvement in knowledge and agreed on the value of CRM training (O'Dea et al., 2014; Sculli et al, 2013). Training, such as what was evaluated in the current study, may be what is needed to truly improve communication among health care teams. All providers must learn to be effective leaders, as well as effective followers, because times will present themselves for both roles. Tools for escalating communication when a patient safety concern is present but attempts to communicate those concerns are not understood is needed. The CRM training provides those tools, and when used effectively, can improve knowledge and behaviors (O'Dea et al., 2014).

Skills required to develop this project were not highly technical in nature. The virtual training modality would be suitable for other health care topics and does not require any special skills or competencies in instructional design or videography. Although a film crew was used for the video vignettes, a stationary video recorder also could have been used, with editing occurring through the use of Camtasia or other editing software. This project resulted not only in a CRM training program (e.g., module, simulations), but also more than 19 video vignettes that could be used independently in the classroom. For example, several of the vignettes depicted different phases of a code situation (e.g., initiation, consideration for interventions, and a debriefing or huddle after a patient code). This may be relevant to an undergraduate nursing transitions or critical care course, where the vignettes could be reviewed as a starting point for further discussion regarding a deteriorating patient. Another vignette depicted poor team interaction (e.g., nursing assistant ignores a plea for help), which could be used in discussions around nursing incivility. Thus, development of video vignettes for a given topic may be useful in other aspects of learning in the academic and clinical settings. In addition, several resources are currently available via open-source materials that could be used for training. For example, the Quality and Safety Education for Nurses Web site offers several teaching modules for various topics associated with quality and patient safety. Prior to the development of new materials, it may be useful to review what is currently available.


Effective communication and teamwork among the interprofessional team is necessary for effective, high-quality care. CRM training has been shown to improve team member knowledge and behaviors, in addition to patient outcomes. Innovative teaching strategies, such as those developed in this study, must be used for widespread dissemination among the interprofessional team as current workflow impedes face-to-face, large-scale training.

Feedback obtained from this evaluation has resulted in additional revisions to the CRM training. Specifically, additional video vignettes have been developed that depict interactions among other team members (e.g., nurses, physicians, social workers, pharmacists), thus improving applicability to the full health care team. The CRM module is ready for widespread dissemination for those interested in improving communication and teamwork among the interdisciplinary team.


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CRM Training Competency and Critical Behaviors

Training ComponentCompetency
Effective leadership critical behaviors

To highlight the specific leadership behaviors that create a participatory team.

To differentiate appropriate leadership behaviors for effective outcomes in a variety of clinical situations.

To outline specific elements of an effective team briefing and huddle.

Effective followership critical behaviors

To identify the attributes of an effective follower.

To outline various types of follower behavior and their effect on team outcomes.

To identify strategies to deliver effective and timely feedback.

To use the effective followership algorithm to manage clinical conflicts.

CRM Module Principles and Video Vignette Overviews

Effective Leadership

CRM PrincipleVideo VignetteVideo Vignette Overview
Type of leader and the leadership gridHigh-task low-concern leaderNurse initiates patient code, directing others as required.
Low-task high-concern LeaderProvider initiates feedback from the team at the conclusion of a patient code.
Interpersonal skillsEffective interpersonal skillsProvider initiates team rounding, introducing self and the plan for the day.
Ineffective interpersonal skillsNurse calls the RRT during a critical situation, but finds the RRT to be less than assistive.
Inviting participationEffective invitationNursing assistant connects with nurse prior to the shift to discuss the plan for the day. The nurse demonstrates an effective and ineffective means for inviting participation.
Ineffective invitation
Asking the team questionsAsking the team questions IProvider asks an open-ended question to the health care team during a procedure.
Asking the team questions IICode leader asks for input from the team regarding next steps during a code situation.
Closed loop communication (CLC)Effective use of CLCCode situation where nurse administers a critical medication demonstrating both effective and ineffective use of CLC.
Ineffective use of CLC
BriefingsHuddleNurse initiates team huddle prior to the start of the shift.
Debriefings and checklistCode leader conducts a debriefing after a successful code.
Effective Followership

CRM PrincipleVideo VignetteVideo Vignette Overview
Type of followersSheepNurse asks for assistance from other nursing staff and is ignored.
Yes manProvider asks for nursing input in patient care. Nurse provides positive response without consideration for what is being asked.
Alienated followerNurse who could provide needed information to other health care team members decides to remain silent, taking the approach that “she learned the hard way.”
Effective followerProvider adds valuable input into a patient's plan of care during team rounds.
CommunicationHint and hopeNurse provides critical information regarding a patient concern to the provider.
The scenarios portray communication through hint and hope, the three Ws, and the 4-step assertive tool.
Effective followership algorithmThree Wsa
4-step assertive tool
Take actionNurse steps in to prevent a third attempt at intubation by an inexperienced provider.
Engage the teamNurse connects with other team members when a time out in the procedural area is denied.
Chain of commandN/A

Dr. Tschannen is Clinical Associate Professor, Director of Post Master's DNP, and Vice Chair of Academic Affairs, Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan.

The support for this project comes from the University of Michigan Health System, Fostering Innovation Grant. Monies provided support for the development of the video vignettes included in the module. The author would also like to extend a special thank you to Dr. Michelle Aebersold, Gary Sculli, and Jill Van Singel for their assistance with module development.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Dana Tschannen, PhD, RN, Clinical Associate Professor, Director of Post Master's DNP, and Vice Chair of Academic Affairs, Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, 400 N. Ingalls, Room 4152, Ann Arbor, MI 48109; e-mail:

Received: February 10, 2017
Accepted: August 23, 2017


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