Folk art is the art of everyday life. Framing homes can be artistic when done with a degree of exemplary expertise. Jerry Saville is a master folk artist because of his special skills and techniques exhibited in his trade of carpentry. This research provides a glimpse into a carpenter’s life to discover what creates and sustains a master carpenter. Through desire, drive, dedication (time/practice), life experience/opportunity (apprenticeship), purpose, and a community of support, Jerry Saville became a master folk artist.

During childbirth, multiple providers deliver care at the bedside that requires optimal teamwork and communication to prevent patient harm. The complexity of caring for obstetrical patient demands a well-coordinated team to relay information and respond to conditions that can change quickly during childbirth. A patient safety strategy to prevent perinatal harm is Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) training. TeamSTEPPS is an evidence-based program based on crew resource management (CRM) principles developed in the aviation and military industries. This process improvement project used the Plan-Do-Study-Act framework and Kotter's change theory to implement TeamSTEPPS training after an increase in patient safety events from 2014 to 2016. A convenience sample of 200 physicians, nurses, respiratory therapists, scrub techs, and patient care techs from perinatal units completed the training in a community hospital setting. The Teamwork Perceptions Questionnaire administered pre- and posttraining show a statistical improvement in teamwork, communication, and situational awareness among nursing staff that correlated with a decrease in safety events. Project limitations include lack of a control group for comparison and lack of physician involvement with training. The positive social impact of TeamSTEPPS training is the decrease in maternal and newborn adverse events surrounding childbirth due to perinatal teams using CRM principles. Over the long term, TeamSTEPPs training may become the standard team training method to improve birth outcomes and support the establishment of a patient safety culture, which may be replicated in perinatal centers around the world.

Nästan var tionde patient i den svenska somatiska sjukhusvården drabbas av en vårdskada och som följd har patientsäkerhetsfrågor aktualiserats. Orsaker till brister i patientsäkerheten kan ofta hittas i organisationen eller arbetsplatsens rutiner där bl.a. bristfälliga rutiner för samverkan och kommunikation är vanliga orsaker. Teamarbete är en vanligt förekommande samarbetsform inom vården och byggstenarna i dessa team utgörs av de teammedlemmar som ingår och som för tillfället arbetar tillsammans. Individernas prestationsförmåga styrs av mänskliga psykologiska och fysiologiska begränsningar vilket leder till att misstag och fel är oundvikliga. Ett system som förebygger, fångar upp och mildrar effekten av dessa fel är Crew Resource Management (CRM). Säkerhetskonceptet, med ursprung inom flygindustrin, har under de senaste decennierna börjat etablerats inom hälso- och sjukvården som ett led i arbetet för att öka patientsäkerheten. Avsikten med CRM är att skapa en säkerhetskultur inom organisationen där det finns en medvetenhet om att fel inträffar och att träna hälso- och sjukvårdspersonal i att hantera dessa. CRM-träning fokuserar på att skapa förutsättningar för ett säkert teamarbetet där bl.a. kommunikation, ledarskap, situationsmedvetenhet och problemlösning är viktiga komponenter. Denna träning i kombination med säkerhetsverktyg, som t.ex. checklistor och kommunikationsstrukturer, används i vardagen för att förstärka samarbetet och bidra till att förebygga och fånga upp fel innan någon kommer till skada. Syftet var att belysa effekten av teamträning i Crew Resource Management. Den metod som valdes var forskningsöversikt med avsikt att kartlägga området och att införskaffa kunskap och träning i att på ett strukturerat sätt sammanställa resultaten från publicerade empiriska studier. Forskningsöversikten redovisar forskningsresultat som publicerats mellan åren 2006-2011. Författarna till forskningsöversikten fann att CRM-interventioner påverkade patientsäkerhetskulturen i positiv riktning även om signifikanta förbättringar inte alltid kunde påvisas. Även patientsäkerheten ökade då flera studier kunde påvisa ett förbättrat utfall för patienterna både när det gällde behandlingsprogram och resultat men även minskad mortalitet efter infört CRM-program. Teamträningen hade dessutom påvisbar positiv effekt avseende medvetenheten och benägenheten att rapportera fel samt minskade antalet rapporterade händelser som kunde kopplas till teamarbete och kommunikation. Teamträning i CRM-principer kan på sikt ha en betydande positiv effekt på patientsäkerheten. Att förändra en säkerhetskultur tar tid och för att uppnå full effekt krävs att upprepad utbildning och teamträning är etablerade delar i CRM-initiativet. Dessutom krävs ett stort engagemang från ledningen där erkännande, stöd och uppmuntran är viktiga komponenter för att uppnå önskad förändring.

The accuracy and similarity of team members' perceptions regarding the interdependencies of their task as well as the criticality of teamwork behaviors is essential to team performance. Unfortunately, these perceptions are not always accurate or similar, which has led to calls for research evaluating the effectiveness of interventions aimed at improving these perceptions. The present study evaluated the accuracy and similarity of crew members' perceptions of task interdependence and teamwork in the U.S. railroad industry. Specifically, this study assessed (1) the effect of Crew Resource Management (CRM) training on the accuracy and similarity of locomotive and maintenance of way (MOW) crew members' perceptions and (2), the extent to which the accuracy and similarity of those perceptions are retained 2-years after training. The overall results of the present study suggests that CRM training is effective in increasing the accuracy and similarity of crew members' perceptions of team-relatedness (amount of task interdependence) and perceptions regarding the importance of teamwork. However, the effectiveness is often dependent on the metric used (i.e., accuracy vs. similarity), and the specific characteristics of the crew members (i.e., locomotive vs. MOW, higher vs. lower interpositional experience). Furthermore, the results suggest that training did not increase the accuracy or similarity of crew members' perceptions of team workflow pattern (form of task interdependence). Lastly, a small sample size and low power precluded the running of quantitative statistical analysis assessing the long-term retention of the accuracy and similarity of participants' perceptions of task interdependence or teamwork. However, for the sake of completeness, the means, standard deviations, and effect sizes are presented in the Appendix.

Crew planning is a complex optimization problem that usually is divided into two separate parts, pairing and rostering. In the rostering process crewmembers are assigned a personal roster, a schedule, for the next coming time period. In order for the crew to have an influence on their roster, SAS have implemented a Preferential Bidding System (PBS) where the crew has the ability to express their wishes regarding their roster, formulated as bids. Generally there is an outspoken dissatisfaction among the crew about PBS and how it works and therefore the questions were raised of how the system could be more transparent and how the bid fulfillment could be communicated both internally and externally. The performed analysis was made with regard to bidding pattern and bid fulfillment and was both quantitative and qualitative. The quantitative part consisted of a thorough review of historic data (delimited to only four months) and a questionnaire, targeting the whole crew collective, was set up as a complementary qualitative analysis. In this thesis the work and result is presented. The result of the analysis shows that satisfaction felt by the crew cannot be directly compared to bid fulfillment as it is measured today. The major aspects of improving the PBS should include a simplification regarding mainly bid types, but also actions in order to increase the transparency of the system and awareness. The recommendation to SAS is to present statistics to crew for each bid type regarding number of placed bids, number of possible fulfillments and how much that is fulfilled thus visualizing the possibility to get a bid fulfilled. A revised range of bid types have also been recommended along with a few minor changes.

Ambulanssjukvården blir allt viktigare i den moderna akutsjukvården då avancerad akutsjukvård kan utföras i prehospital miljö. World Health Organization menar att bristande kommunikation är orsaken till upp emot 70 procent av alla händelseavvikelser. Kommunikation i teamet har stor betydelse för samarbetet kring den skadade/sjuka patienten. Syftet var att undersöka kommunikation hos ambulansteamet vid simulerade prehospitala patientfall under utbildning i Crew Resource Management (CRM). Urvalet bestod av tolv deltagare där samtliga arbetade inom ambulanssjukvård. Datainsamlingen skedde i samband med ett utbildningsprojekt i ett ambulansdistrikt i södra Sverige och bestod av 12 stycken filmer. Dessa analyserades med hjälp av kvalitativ innehållsanalys med deduktiv ansats. I resultatet framkom tre kategorier utifrån befintliga nyckelord i CRM, adressering, readback och teamsummering. Analysen visar att de flesta fallen blir strukturerade genom kroppsspråk, ögonkontakt, att tala högt, även vid ickeadressering, icke-readback eller icke-teamsummering. Icke-verbal kommunikation såsom kroppsspråk spelar stor roll vid kommunikation i teamet. Ytterligare forskning behövs inom området för att förstå vilka effekter kommunikationen har kopplat till patientsäkerhet i det akuta prehospitala patientomhändertagandet. / Ambulance services are becoming more important in modern emergency medical care as advanced emergency medical care can be carried out in the prehospital environment. According to World Health Organization poor communication causes as much as 70% of all healthcare errors. Communication in the team is of great importance for the teamwork when working with an injured/ill patient. The aim was to study communication in the ambulance team at simulated prehospital cases during an education in Crew Resource Management (CRM). The data selection consisted of twelve participants, all of whom worked in ambulance care. The data collection took place in connection with a training project in an ambulance district in southern Sweden and consisted of 12 films. These were analyzed by means of qualitative content analysis with deductive approach. The results presented three main categories based on existing keywords in CRM, addressing, readback, and team summary. The analysis show that most cases are structured through body language, eye contact, talking loudly, even at non-addressing, non-readback or non-teamsummering. Non-verbal communication like body language plays an important role in communication with the team. Further research is needed in this area to understand what effects the communication is linked to patient safety in the emergency pre-hospital patient care.

The Rowing Coaches is about friendship, money, love, loss, and rowing. It chronicles the turning point in the lives of three friends who are professional rowing coaches. The friends are Don Bestos, Bill Maxwell, and Bergman, men who are or were at the very top of their sport, and now question their friendships with each other and where their lives are headed. The story takes place on a weekend in the summer of 2000 at the USRowing Convention in Las Vegas, the big blow-out for everyone in the sport of rowing. The Rowing Coaches also offers a look at an esoteric and often misunderstood sport. The main character is Don Bestos, a fifty-year-old head coach from Northeastern University. Don is recently divorced and has yet to move on from the failure of his marriage. The memory of his ex-wife Annie causes him physical pain and occasionally haunts him. Don is in crisis and he questions what he has done with his life and whether he can continue with his chosen career. Don's concerns are compounded by his alcoholism. He grapples with his addiction throughout the story. Don also has a peculiar gift; upon touching certain inanimate objects, such as a boat, he can sense if the object has a soul. Don's best friend is Bergman, the obese head coach from the University of Pennsylvania. Bergman's team has been losing for years and he has lost the drive to continue as an elite rowing coach. Bergman is a loyal friend and he watches out for his friends. The one coach who appears to be on the upswing is Billy Maxwell, Don's assistant coach at Northeastern. Billy is a former Olympian and he is considered one of the rising stars in the coaching profession. Billy has been a winner at every level in the sport and he is willing to sacrifice everything to win, even friendship. Other characters include Stacy Kookla, a sociable sales representative for the top rowing boat manufacturer in the country; Andy Carr, the head coach of Yale University; and Missy Krajcik, the fastest female rower in the world.

This work evaluates SiteManager, the construction documentation system used by VDOT, as a tool for collecting the daily installed quantity and active crew days necessary to populate the operations level of the database. This evaluation first sought to determine if SiteManager was a feasible option for collecting performance data. This was done by establishing data collection methods to enable SiteManager to have the ability to collect performance data, implementing the methods on select projects, resolving issues, and developing recommendations to cause SiteManager to be a more practical option. Secondly, a statistical analysis was performed to determine if the data collected from SiteManager was reasonably accurate. Thirdly, the technical issues of transferring performance data from SiteManager into the performance time database were resolved. It was found SiteManager could not be used in its current format to collect performance data and some modifications are required. / Master of Science

There are many pieces of flight deck research on general use of written English language technical information and problem solving using technical documentation. Contributory causes of aircraft accidents have been due to misunderstandings of crew alerts and procedural divergence by English as-a-second language flight crewmembers (ESL). Research was conducted to understand impact of written English language technical information on ESL flight crewmembers’ performance. Two types of systems were evaluated, technical documentation and crew alerting systems that contain technical information, with respect to their impact on ESL flight crewmember performance. Preliminary analysis results indicated written English language technical information can be confusing, difficult to read and interpret, and leads to misunderstandings by ESL flight crewmembers during aircraft nonnormal conditions. English as-a-second language flight crewmembers indicated they often experience problems executing written English language technical procedures after outset of crew alerts. Conversely, experimental trials revealed ESL flight crewmembers did not experience many cognitive performance issues with use of crew alerting systems and technical information designed with an English language emphasis. English as-a second language flight crewmembers’ English language proficiency, background knowledge, and use of use of metacognitive strategies to read and comprehend written English language on crew alerting and information systems, indicated they utilized written English technical information with ease. Particularly, ESL flight crewmembers’ workload was low, they had fast response times to system faults, and they experienced minimal procedural deviations. On the contrary, when ESL flight crewmembers utilized written English language technical procedures translated into their native language during non-normal conditions, they experienced several cognitive performance challenges. English as-a second language flight crewmembers’ background knowledge of written English language technical information translated into their native language, use of metacognitive strategies to read and comprehend written English language translated into their native language, indicated they experienced difficulties with reading and comprehending translated technical information on information systems. Particularly, ESL flight crewmembers were challenged cognitively when they responded to crew alerts through execution of decision-making processes. They indicated translation of written English language technical information into their native language was a pre-cursor to procedural deviation, long response times to system issues, as well as high workload during experimental trials. It is recommended that further research focus on design and use of written English language technical documentation by ESL flight crewmembers during non-normal conditions. It is also recommended that if deemed practical by the aviation industry, further research should focus on design, integration, and utilization of technical documentation in a language(s) other than English, and measurement of ESL flight crewmembers performance on the flight deck.

There are many pieces of flight deck research on general use of written English language technical information and problem solving using technical documentation. Contributory causes of aircraft accidents have been due to misunderstandings of crew alerts and procedural divergence by English as-a-second language flight crewmembers (ESL). Research was conducted to understand impact of written English language technical information on ESL flight crewmembers’ performance. Two types of systems were evaluated, technical documentation and crew alerting systems that contain technical information, with respect to their impact on ESL flight crewmember performance. Preliminary analysis results indicated written English language technical information can be confusing, difficult to read and interpret, and leads to misunderstandings by ESL flight crewmembers during aircraft nonnormal conditions. English as-a-second language flight crewmembers indicated they often experience problems executing written English language technical procedures after outset of crew alerts. Conversely, experimental trials revealed ESL flight crewmembers did not experience many cognitive performance issues with use of crew alerting systems and technical information designed with an English language emphasis. English as-a second language flight crewmembers’ English language proficiency, background knowledge, and use of use of metacognitive strategies to read and comprehend written English language on crew alerting and information systems, indicated they utilized written English technical information with ease. Particularly, ESL flight crewmembers’ workload was low, they had fast response times to system faults, and they experienced minimal procedural deviations. On the contrary, when ESL flight crewmembers utilized written English language technical procedures translated into their native language during non-normal conditions, they experienced several cognitive performance challenges. English as-a second language flight crewmembers’ background knowledge of written English language technical information translated into their native language, use of metacognitive strategies to read and comprehend written English language translated into their native language, indicated they experienced difficulties with reading and comprehending translated technical information on information systems. Particularly, ESL flight crewmembers were challenged cognitively when they responded to crew alerts through execution of decision-making processes. They indicated translation of written English language technical information into their native language was a pre-cursor to procedural deviation, long response times to system issues, as well as high workload during experimental trials. It is recommended that further research focus on design and use of written English language technical documentation by ESL flight crewmembers during non-normal conditions. It is also recommended that if deemed practical by the aviation industry, further research should focus on design, integration, and utilization of technical documentation in a language(s) other than English, and measurement of ESL flight crewmembers performance on the flight deck.