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

The study, conducted between 2022 and 2023 using a constructivist grounded theory approach, did not simply ask clinicians to describe their routines. Researchers used semi-structured interviews lasting 45 to 60 minutes, supplemented with hypothetical patient vignettes that allowed participants to reason through realistic cases without feeling personally exposed. Data collection and analysis ran in parallel, with each interview transcribed verbatim and coded line by line using constant comparison, a process supported by MAXQDA software. From this iterative analysis a core category emerged that captures the entire dilemma: healthcare professionals are striving to enhance cardiovascular risk awareness in their patients while balancing responsibility and uncertainty.

That balancing act begins with assessment itself. The clinicians described monitoring HbA1c, blood pressure, lipid levels and lifestyle habits, but they openly admitted that it was difficult to know which parameter best reflected a patient’s true cardiovascular risk. Some focused primarily on blood sugar; others prioritised cholesterol before turning their attention to glycaemic control. Almost all relied on risk visualisation tools from the Swedish national diabetes register, and physicians additionally used standardised instruments such as SCORE2 to classify risk as high or low. Yet the tools cut both ways. Some professionals refrained from formal risk assessment altogether because navigating multiple systems was perceived as time-consuming and cumbersome, meaning that cardiovascular risk in those cases went inadequately communicated.

Even when assessment succeeded, translation into understanding proved far harder. Participants described painstaking efforts to identify what each patient actually knew, asking individuals to explain in their own words why they were attending the visit and what they understood about their disease. They built step-by-step visual pictures, used metaphors and explanatory models to illustrate blood sugar and lipid levels, and checked comprehension by asking patients to recount what had been agreed. One diabetes nurse explained the stakes bluntly: poorly adapted information is wasted, so she tried to be clear about risks of vision changes, stroke, heart attack and kidney failure without wrapping the message too vaguely. Notably, some clinicians communicated microvascular complications while hesitating over macrovascular ones, sometimes splitting the risk message across different moments in the same visit.

The emotional dimension of this work emerged as perhaps the most striking finding. Clinicians reported genuine frustration and even feelings of failure when they could not reach certain patients, and some described the painful necessity of prioritising those willing to attempt change over those who were not, a decision one nurse called very difficult to make. Patients who expressed shame at missing treatment targets posed a particular challenge, as did patients perceived as fearful, overwhelmed by information, or struggling with mental health difficulties, in whose cases some professionals admitted avoiding risk discussions altogether. The clinicians walked a constant tightrope between encouragement and demand, wanting to convey seriousness without resorting to scare tactics or blame, and recognising that fear alone rarely produces sustainable lifestyle change.

Trust emerged as the currency that made any of this possible. Participants described building professional yet personal relationships, drawing on their own experiences, offering advice anchored in the patient’s actual life, and reinforcing progress to instil hope. Continuity was identified as crucial, because trust accumulates over repeated encounters rather than single appointments. Yet the organisational reality worked against this ideal. Many patients received only one visit per year instead of the guideline-recommended two, appointments became checklist-oriented and conveyor-belt-like, and limited time for follow-up questions hindered meaningful dialogue. Some clinicians encouraged patients to write down questions for their next visit as a workaround, a small and telling adaptation to systemic shortage.

Beneath the individual struggles lay a deeper structural problem: the diabetes team, in any meaningful sense, often did not exist. Diabetes specialist nurses described feeling alone in carrying overall responsibility for patients with type 2 diabetes, absorbing duties that would ordinarily fall to physicians because of chronic doctor shortages. Patients rarely met a physician in a planned manner, and nurses and doctors sometimes applied different strategies to the same patient, creating uncertainty about how treatment and risk communication should proceed. Some nurses admitted they did not always trust the clinical decisions of the physicians they worked with. Both professions called for shared responsibility, a common working model, structured diabetes-focused meetings and greater consensus, so that patients would hear consistent information from every member of the team.

The study’s authors argue that these findings reframe cardiovascular risk communication not as a simple transfer of information but as an ongoing, dynamic dialogue shaped in real time by the tension between objective medical data and patients’ subjective interpretations. Risk calculators and visual tools, however sophisticated, proved insufficient on their own to raise awareness or change behaviour, which helps explain why patients so often report not receiving or not understanding risk information. The researchers suggest that person-centred communication requires more than adapting facts to individual patients; it demands creating shared meaning about what risk actually signifies for a particular life, listening to patient narratives and addressing emotional and existential concerns before expecting behavioural change to follow.

The implications reach well beyond northern Sweden. The authors acknowledge limitations, including recruitment difficulties that forced reliance on snowball and convenience sampling, a predominantly female participant pool, and digital interviews that may have limited rapport, but they note that similar themes emerged across participants of varying age, sex, experience and setting, suggesting robust consistency. Their recommendations are pointed: healthcare systems must provide clinicians with the time, continuity, staffing and team structures without which even the most skilled communicator cannot succeed, and future research should explore collaboratively with patients how cardiovascular risk can be conveyed without vagueness or threat. Until then, the professionals on the front line of the diabetes epidemic will continue doing what this study documents so vividly: shouldering an enormous communicative burden alone, hoping their words reach patients before a heart attack makes the message unmistakably clear.

Subject of Research: Cardiovascular risk communication to people with type 2 diabetes in primary healthcare

Article Title: Primary Healthcare Professionals' Perspectives on Cardiovascular Risk Communication to Persons With Type 2 Diabetes: A Grounded Theory Study

Article References: Stenlund, A.-L., Hellström Ängerud, K., Lilja, M., Otten, J., & Jutterström, L. (2026). Primary Healthcare Professionals' Perspectives on Cardiovascular Risk Communication to Persons With Type 2 Diabetes: A Grounded Theory Study. Nursing Open, 13(9), Article e70828. https://doi.org/10.1002/nop2.70828

Image Credits: AI Generated

DOI: 10.1002/nop2.70828

Keywords: type 2 diabetes, cardiovascular risk, risk communication, primary healthcare, grounded theory, diabetes specialist nurses, person-centred care, patient self-management, healthcare teams, Sweden, qualitative research, HbA1c