How to ‘10-for-10’: a qualitative research protocol to determine best practice use of the 10-for-10 principle

Abstract

Introduction

Critical situations in clinical medicine are associated with high cognitive load, time pressure and an increased risk to patient safety. Crisis Resource Management aims to address these challenges through skills such as communication, situational awareness, task management, team performance and decision-making. The ‘10-for-10 principle’, which encourages clinicians to pause briefly to reassess and plan ahead, is widely taught in simulation-based training and applied in clinical practice throughout German-speaking countries. Despite its widespread use, the principle lacks a clear scientific definition and has not been systematically investigated. This study aims to develop an empirically informed conceptual understanding of this principle based on expert perspectives as an early exploration, a foundation for future research and educational model development.

Methods and analysis

This qualitative study will use 15–20 semistructured expert interviews to explore current applications, variations, structural components and perceived barriers related to the 10-for-10 principle, aiming to provide an early exploration of the principle across German-speaking countries. Participants will be purposively sampled from clinical and simulation-based education contexts. Data collection and analysis will be conducted concurrently using the iterative content-structuring qualitative approach as described by Kuckartz and Rädiker. Deductive codes derived from existing conceptual descriptions will be combined with inductively developed codes informed by expert narratives to identify core categories across interviews. Findings will be synthesised into a taxonomy organised by expert-perceived relevance and frequency of reference.

Ethics and dissemination

Ethical approval has been obtained from the Ethics Committee of Charité—Universitätsmedizin Berlin (EA 1/093/25). Written informed consent will be obtained from all participants. Data will be pseudonymised and handled in accordance with institutional and data protection regulations. Study findings will be disseminated through peer-reviewed publication and conference presentations and are intended to inform future empirical research and the development of simulation-based educational approaches related to the 10-for-10 principle.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The combination of deductive and inductive category development within qualitative content analysis enables systematic analysis while remaining open to aspects emerging from the interview data.

• The use of expert interviews enables the structured elicitation of practice-based knowledge and the exploration of variations, structural elements and implementation barriers from different expert perspectives.

• The study is limited by its restriction to German-speaking experts which may result in the unintended exclusion of relevant perspectives and limit transferability of findings to other linguistic and cultural contexts.

• The research team’s subject-matter expertise may influence data collection and interpretation; however, reflexive strategies are employed to mitigate potential bias.

Introduction

Critical situations in the medical field are frequently characterised by high complexity, incomplete information and significant time pressure and are therefore associated with an increased risk of treatment errors and an immediate threat to patient safety.^1–3 Such scenarios require excellent situational management of the entire therapeutic team.

Over the past three decades, substantial academic and practical effort has been devoted to developing mental models and training strategies that support medical personnel in acting rapidly, safely and reliably under stress. Famously, Howard et al and Gaba pioneered the transfer of Cockpit Resource Management concepts from aviation into healthcare, introducing what became known as Crisis Resource Management (CRM) in medicine.^{4 5} In the early CRM literature, CRM is described as a set of non-technical skills for managing critical situations, primarily addressing aspects such as effective communication, situational awareness, decision-making, task-management, team performance and leadership. Since then, CRM has been operationalised through simulation courses, workshops, educational materials and implementation guides, with the 15 key principles of Anaesthesia Crisis Resource Management described by Rall et al forming the predominant foundation of instructional practices.^{4 6 7}

Within this framework, Rall et al described the ‘10-for-10 principle’ in a short publication in more detail.⁸ Its objective is to encourage clinicians to pause for approximately 10 s to reassess and plan the next 10 min of patient care—the suggested timeframe is intentionally flexible rather than prescriptive. Despite widespread dissemination, empirical research supporting CRM remains limited,^9–12 and the 10-for-10 principle itself has never been subjected to scientific investigation. Published knowledge is restricted to the brief conceptual description by Rall et al, with no established evidence on its content, internal structure, outcome relevance or implementation contexts. Nevertheless, in Germany, Austria and Switzerland, the principle has been widely embedded into clinical routine and CRM education and has been in use for more than a decade.

Although the initial publication described an international project, the 10-for-10 principle appears to be predominantly used across German-speaking countries. However, the concept of pausing during a critical situation appears to be an internationally recognised strategy in dynamic and critical medical situations, with different terms describing similar principles.^13–17 Nevertheless, the literature on this topic remains limited, particularly regarding its structure, content, conceptual basis and evidence for its effectiveness and potential use cases. Given the variety of terminology used, it is important to distinguish the 10-for-10 principle and related concepts from the operating room huddle, which is typically conducted at the beginning of the day, and from the ‘time-out’ recommended by the WHO as part of routine surgical safety procedures.^{18 19}

In light of this lack of empirical investigation and conceptual clarity, the present study protocol proposes a qualitative research approach to systematically explore the current use of the 10-for-10 principle across German-speaking countries as an early exploration study. The primary aim is to develop an empirically informed working definition and structural understanding of the principle based on expert knowledge. Establishing such a scientific foundation is a necessary prerequisite for the future development of a structured teaching model for simulation-based training. Although no empirical evidence currently exists to demonstrate a direct impact of the 10-for-10 principle on patient outcomes, a transparent and systematically derived conceptual model may facilitate its consistent and reflective use in educational settings as well as clinical practice, with the overarching goal of improving team performance, supporting decision-making processes and ultimately patient safety. To achieve this, expert interviews will be conducted to elicit experiential and practice-based knowledge.

This study aims to address the following research questions:

• How do existing variants of the 10-for-10 principle in the clinical routine differ in structure and application?

• Which structural features of the 10-for-10 principle potentially contribute to improvements in CRM relevant aspects according to experts’ opinion?

• Which content-related elements of the 10-for-10 principle are perceived as most relevant for enhancing CRM relevant aspects?

• What obstacles and contextual barriers may hinder the practical implementation of the 10-for-10 principle in critical situations?

Methods and analysis

Study overview and design

This study adopts a qualitative research design using expert interviews to explore current applications, interpretations, and variations of the 10-for-10 principle. Qualitative expert interviews are particularly suited to investigating experiential and practice-based knowledge through non-standardised or semistandardised data collection and interpretative analytical approaches.²⁰ In contrast to standardised quantitative methods such as surveys, qualitative designs allow for the identification of previously unrecognised themes and contextual factors relevant to clinical practice. To support methodological rigour and transparent reporting, the study is designed in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) and the Standards for Reporting Qualitative Research (SRQR).^{21 22}

Sampling strategy and participant selection

Expertise is defined according to an institutionalised, role-based conceptualisation that emphasises formalised knowledge, professional status, and acknowledged authority within the specialist community.^23–25 Participants will be purposively sampled from the Charité University network as well as through review of published literature. Additional experts may be identified using snowball sampling following initial recruitment to broaden the range of perspectives.

To support sample heterogeneity, recruitment will span different healthcare professions, medical specialties and German-speaking countries (Germany, Austria and Switzerland). These countries constitute the predefined German-speaking context of the study and will not be treated as separate comparison groups.

Because the 10-for-10 principle is primarily applied in the clinical management of critical situations and disseminated through simulation-based medical education, the study population will include both clinical experts with experience using the principle in real-world settings and experts involved in simulation-based training or CRM instruction. The inclusion of both perspectives is intended to capture complementary perspectives on practical implementation and educational conceptualisation.

Eligibility criteria include:

1. Healthcare professionals (eg, physicians, nurses, midwives, prehospital emergency personnel) working in disciplines with frequent exposure to critical situations (including anaesthesiology, intensive care, emergency medicine, surgery, obstetrics or prehospital emergency services).

2. Non-medical professionals with expertise in communication, human factors or team performance in medical settings (eg, psychologists, human factors specialists). All participants must additionally.

3. Have knowledge of or practical experience with the 10-for-10 principle and CRM in a medical context.

4. Be proficient in the German language.

Eligible individuals will receive a standardised study invitation letter and brief preinterview questionnaire assessing experience with the 10-for-10 principle. Written informed consent will be obtained prior to interview scheduling. Participant characteristics derived from the questionnaire will be summarised in tabular form. No incentives will be offered to experts participating in the interviews; they will receive no monetary or other form of compensation for their participation.

Based on considerations of information power, we anticipate conducting approximately 15–20 interviews as an initial estimate rather than a predefined sample size or stopping point.²⁶ Sample adequacy will be assessed based on meaning saturation, considering whether additional interviews provide substantively new dimensions, variations, or relevant differentiations within categories central to the research questions.²⁷ Recruitment will continue beyond the anticipated sample size if meaning saturation has not been reached.

Participants are not anticipated to have prior personal relationships with the investigators. In cases where collegial familiarity exists, interviews will be conducted by a researcher with no prior contact with the participant. This strategy, in combination with a standardised semistructured interview guide, is intended to minimise potential bias related to personal relationships.

Research team and reflexivity

This study was conceptualised and designed by a multidisciplinary research team based at the Berlin Simulation and Training Centre, comprising three physicians with expertise in anaesthesiology, intensive care, emergency medicine and medical simulation, one human factors specialist, and one intensive care nurse holding a master’s degree in public health. The team includes two women and three men and integrates clinical, educational and methodological expertise.

Given the research team’s dual role as subject-matter experts and qualitative researchers, reflexivity will be actively supported through the systematic use of memos as described by Kuckartz and Rädiker.^{28 29} Researchers will document prior assumptions and overarching reflections in free memos, while interviewers will record relevant post-interview observations in document memos. During analysis, in-document memos and code memos will be used to document passage-specific reflections and the development of categories. These memos will inform subsequent analysis and team discussions, allowing assumptions, interpretations, and analytic decisions to be critically reviewed throughout the research process.

Interview context and setting

Interviews will be conducted online via Microsoft Teams (Microsoft Corporation, Redmond, Washington, USA). As standard, two members of the research team will be present: the interviewer—typically the researcher who conducted participant contact—and a second researcher to provide technical support if needed. Interviews will be conducted in the same office setting to ensure a controlled and distraction-free environment.

Semistructured interview guide

The semistructured interview guide was developed based on systematic reviews of current CRM and simulation literature, combined with prior clinical knowledge and internal team discussions.^{9 10 11 12} Open-ended questions allow for structured inquiry while enabling participants to introduce emergent topics. The interview guide will be applied flexibly, allowing participants to introduce unanticipated aspects relevant to the research questions and interviewers to explore these through follow-up questions.^{28 30} Online supplemental file 1 provides the complete interview guide.

Data collection

Data collection is expected to occur over a period of up to 3–6 months starting at the end of 2026. To evaluate question clarity and interview flow, up to three pilot interviews will be conducted with clinical volunteers. Each interview is expected to last approximately 60–75 min including briefing and debriefing. Repeated interviews are not planned. Interviews will be audio-recorded using a Jabra SPEAK2 40 voice recorder and transcribed verbatim. Transcriptions will be produced using the opensource, offline software noScribe³¹ and will adhere to the orthographic transcription rules of Dresing and Pehl, prioritising standardised reproduction of spoken content.^{32 33} Transcripts may be returned to participants for comment or correction on request.

Following each interview, the interviewer will create a document memo to record relevant observations and reflections on the interview situation and the interview as a whole.²⁸

Data analysis

Data collection and analysis will be conducted concurrently using the iterative qualitative content-structuring approach by Kuckartz and Rädiker; see figure 1 for an overview.²⁹ An a priori coding framework was developed based on the conceptual description of the 10-for-10 principle by Rall et al and comprises two primary deductive domains: (1) structural features and (2) content-related elements of the principle. Additional inductive codes addressing variations of the 10-for-10 principle and barriers to implementation were informed by the clinical and educational expertise of the research team.

Figure 1. Methodological study overview. Study design and reporting were guided by the COREQ and SRQR guidelines. ¹Data collection and analysis follow the content-structuring qualitative analysis approach described by Kuckartz and Rädiker.^{29 2}Reflexivity is supported throughout the research process through the systematic use of memos and critical discussion of assumptions, interpretations and analytical decisions within the research team. COREQ, Consolidated Criteria for Reporting Qualitative Research; CRM, Crisis Resource Management.

All codes will be defined using explicit operational definitions and application examples to support transparent coding decisions and enhance inter-coder consistency. Data analysis will follow the flexible, comparative approach of qualitative content analysis as described by Kuckartz and Rädiker. Each transcript will undergo multiple iterative coding cycles across the seven phases of content-structuring qualitative analysis, including familiarisation with the data, category development, deductive and inductive coding, and ongoing refinement in relation to the research questions.²⁹ Memos generated throughout data collection and analysis will inform the analytical process and team discussions.

Coding will be conducted independently by two authors (JB and JE), allowing for comparison and discussion of coding decisions to enhance analytical rigour and consistency. Differences in coding will be discussed until consensus is reached. The coding and organisation of the data will be supported by the qualitative data analysis software MAXQDA 26.³⁴

Study findings will be presented as a taxonomy organising identified categories according to expert-perceived relevance and frequency of reference. Relevance will be determined through qualitative interpretation of expert statements indicating central and essential aspects of the 10-for-10 principle. Frequency of reference will reflect how commonly specific aspects are addressed across interviews without implying explicit importance. The combined consideration of relevance and frequency is intended to identify core components of the 10-for-10 principle from a practice-oriented expert perspective.

Patient and public involvement

Patients and members of the public were not involved in the design, conduct, reporting or dissemination plans of this research.

Ethics, data protection and dissemination

Ethical approval for this study, including all procedures relating to data collection, storage and analysis, was obtained from the Ethics Committee of Charité—Universitätsmedizin Berlin (EA 1/093/25) in April 2025.

To ensure confidentiality and compliance with data protection standards, no directly identifying personal data will be collected. Participants will be explicitly instructed during the preinterview briefing to refrain from disclosing identifiable information about themselves or third parties. If person-identifying information is nonetheless disclosed during the interview, pseudonymisation will be applied during the transcription process. This will be achieved by deleting identifying details and replacing them with standardised placeholders. Full anonymisation will be completed after data analysis through permanent deletion of the pseudonymisation key.

Anonymised transcripts will be stored for 10 years on a secure internal Charité server in accordance with institutional and legal requirements. Audio recordings will be permanently deleted within 7 days after each interview has been completed and verified for transcription accuracy.

Study findings will be disseminated through publication in a peer-reviewed journal and presentation at relevant scientific conferences.

Strengths and limitations

This study addresses a relevant gap in the literature by systematically examining the 10-for-10 principle, a widely used yet insufficiently defined component of CRM in clinical practice and simulation-based training. The qualitative expert interview design is well suited to exploring this under-researched phenomenon, as it enables the structured elicitation of practice-based knowledge and the identification of variations, structural elements and implementation barriers that are not fully accessible through quantitative methods. By applying a transparent and iterative qualitative framework, the study aims to generate an initial conceptual taxonomy that may inform future empirical and simulation-based research and support the development of an evidence-informed teaching model.

Several limitations should be acknowledged. Expert interviews are time-intensive. While purposive expert sampling is methodologically appropriate, the recruitment through established professional networks and literature sources may limit the diversity of views captured. In addition, restricting the sample to German-speaking experts limits the transferability of findings to other linguistic and cultural contexts. Finally, the research team’s subject-matter expertise may influence data collection and interpretation; however, this risk will be addressed through reflexive practices, including the systematic use of memos and critical discussion of assumptions and interpretations within the research team. At the same time, this domain expertise represents a methodological strength, supporting the development of contextually grounded interview guides and analytical categories.