Aviation-Style Team Training Takes Root in Pediatric Hospital Wards, Study Finds

Crew Resource Management, the set of communication and teamwork principles that transformed aviation safety after researchers determined that most cockpit disasters stemmed from human and team failures rather than technical faults, has been quietly reshaping practice at a Dutch children’s hospital for nearly two decades. A new multi-method qualitative study from Erasmus MC-Sophia Children’s Hospital in Rotterdam, published in BMC Medical Education, examines a question that has long troubled patient-safety researchers: what does it actually take to keep such training programs alive and effective years after the initial enthusiasm fades?

The research team, led by Ada van den Bos-Boon of the Department of Neonatal and Pediatric Intensive Care together with Martina Buljac-Samardzic of the Erasmus School of Health Policy and Management, set out to explore the long-term sustainability of Crew Resource Management, commonly abbreviated as CRM, in pediatric hospital care. Rather than asking simply whether CRM works, the investigators asked how CRM practices evolve and endure across departments with very different levels of experience, and which facilitators and barriers shape their adoption and maintenance over time.

To answer that question, the team designed a multi-method qualitative study spanning three departments of a single tertiary children’s hospital: the pediatric intensive care unit, known as the PICU, and two intermediate care units, the non-ICU neurology ward and the pediatric thoracic surgery ward. The three settings offered a natural experiment in longevity, with 17, 5, and 6 years of CRM experience respectively. In total, 44 healthcare professionals participated. Data came from focus groups with 20 participants, individual interviews with 24 participants, and direct observations of daily clinical practice, allowing the researchers to triangulate what staff said about CRM with what they actually did at the bedside.

The analytical backbone of the study was the Consolidated Framework for Sustainability Constructs in Healthcare, a structured model that helps researchers organize the many factors influencing whether an intervention survives after implementation. Using this framework, the team mapped themes emerging from the focus groups, interviews, and observations, comparing how CRM practices had matured, adapted, or eroded in each department over years of real-world use.

The findings paint a picture of divergence rather than uniformity. CRM practices evolved differently across the three departments, shaped by contextual factors unique to each clinical environment. The pediatric intensive care unit, with its 17 years of accumulated experience, and the two younger intermediate care units did not simply converge on a shared way of working. Instead, each department developed its own local version of CRM, suggesting that sustainability is less about preserving a fixed program and more about allowing practices to adapt while keeping their core principles intact.

Four facilitators emerged as especially important for keeping CRM alive. Strong leadership support, at all levels of the organization, gave teams the confidence and resources to keep practicing CRM behaviors. Tailored implementation, meaning that training and tools were adapted to the specific needs and dynamics of each department, made the practices feel relevant rather than imposed. Team ownership proved equally critical: when frontline staff felt genuine responsibility for CRM rather than viewing it as a management initiative, the behaviors became embedded in daily routines. Finally, active feedback mechanisms, in which teams continuously reflected on their communication and collaboration, reinforced the principles over the long term.

The barriers the researchers identified were just as instructive. Unclear procedures left staff uncertain about how and when to apply specific CRM tools, such as SBARR, the structured communication format covering situation, background, assessment, recommendation, and readback. The absence of formal follow-up agreements meant that once initial training ended, there was often no scheduled mechanism to refresh skills, onboard new staff, or monitor whether practices were drifting. Uneven psychological safety posed a third challenge: in settings where some team members did not feel safe speaking up, the speak-up culture at the heart of CRM could not function consistently, undermining the very behaviors the training was designed to instill.

Importantly, the study suggests these barriers are not fatal. The researchers found they could be mitigated through department-specific adaptations and through continuous reinforcement of CRM principles in everyday practice. In other words, sustainability appears to depend on treating CRM not as a one-time course but as a living system that requires periodic calibration, clear procedures, and deliberate cultivation of an environment where every team member, from senior physician to junior nurse, can raise concerns without fear.

The implications reach well beyond a single hospital. Healthcare organizations worldwide have invested heavily in team training programs borrowed from high-risk industries such as aviation, yet studies repeatedly show that the effects of such interventions decay without sustained support. This study offers a rare long-term view, drawn from departments with up to 17 years of CRM experience, and indicates that longevity hinges on local tailoring, engaged leadership, and structured follow-up strategies rather than on the training content alone. Strengthening shared responsibility among team members, the authors conclude, is essential to long-term success.

The researchers also point to the limits of what their design can show. As a qualitative study conducted in three departments of one tertiary children’s hospital, its findings describe mechanisms rather than measure outcomes, and the authors call for future research to assess the impact of different leadership models and tailored strategies on CRM sustainability. Even so, the message for hospitals is concrete: if you want aviation-grade teamwork in clinical care, plan for the decade after the workshop ends, because that is when sustainability is truly decided.

Subject of Research: Long-term sustainability of Crew Resource Management training and tools in pediatric hospital care

Article Title: Exploring sustainable Crew Resource Management (CRM) training and tools in pediatric hospital care: a multi-method approach

Article References: van den Bos-Boon, A., van der Starre, C., Houmes, R.-J., Gischler, S., van Dijk, M., & Buljac-Samardzic, M. (2026). Exploring sustainable Crew Resource Management (CRM) training and tools in pediatric hospital care: a multi-method approach. BMC Medical Education. https://doi.org/10.1186/s12909-026-10524-z

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10524-z

Keywords: Crew Resource Management, pediatric hospital care, team training, patient safety, qualitative research, healthcare teams, interprofessional collaboration, implementation science, leadership, psychological safety, medical education, sustainability