Toward a Definition of Teamwork in Emergency ... - Wiley Online Library

Toward a Definition of Teamwork in Emergency Medicine Rosemarie Fernandez, MD, Steve W. J. Kozlowski, PhD, Marc J. Shapiro, MD, Eduardo Salas, PhD

Abstract The patient safety literature from the past decade emphasizes the importance of teamwork skills and human factors in preventing medical errors. Simulation has been used within aviation, the military, and now health care domains to effectively teach and assess teamwork skills. However, attempts to expand and generalize research and training principles have been limited due to a lack of a well-defined, wellresearched taxonomy. As part of the 2008 Academic Emergency Medicine Consensus Conference on ‘‘The Science of Simulation in Healthcare,’’ a subset of the group expertise and group assessment breakout sections identified evidence-based recommendations for an emergency medicine (EM) team taxonomy and performance model. This material was disseminated within the morning session and was discussed both during breakout sessions and via online messaging. Below we present a well-defined, well-described taxonomy that will help guide design, implementation, and assessment of simulationbased team training programs. ACADEMIC EMERGENCY MEDICINE 2008; 15:1104–1112 ª 2008 by the Society for Academic Emergency Medicine Keywords: patient simulation, team training, team effectiveness, patient safety

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he importance of team training and assessment to patient safety and clinical practice is reported throughout the simulation and health care quality literature. Emergency medicine (EM) is often a focal point of these discussions due to the dynamic, complex nature of the work environment and its interdisciplinary nature.1 Several reports outline simulation-based team training interventions and assessments in health care2–4 and, more specifically, EM.5,6 Unfortunately, small sample sizes and selection of study sites limit the generalizability of these study outcomes.7 Although most current team training programs are based on aviation’s crew resource management or military programs, a unifying taxonomy and framework is lacking. Inconsistencies in From the Department of Emergency Medicine and Office of Academic and Student Programs, Wayne State University School of Medicine (RF), Detroit, MI; the Department of Psychology, Michigan State University (SWJK), East Lansing, MI; the Department of Emergency Medicine, Alpert Medical School, Brown University (MS), Providence, RI; and the Department of Psychology, Institute for Simulation & Training, University Central Florida (ES), Orlando, FL. Received July 8, 2008; revision received July 15, 2008; accepted July 17, 2008. This is derived from the proceedings of the 2008 Academic Emergency Medicine Consensus Conference ‘‘The Science of Simulation in Healthcare: Defining and Developing Clinical Expertise,’’ Washington, DC, May 28, 2008. Address for correspondence and reprints: Rosemarie Fernandez, MD; e-mail: [email protected].

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ISSN 1069-6563 PII ISSN 1069-6563583

definitions and use of team skill labels result in confusing and contradictory statements, ultimately limiting generalizability.8,9 In a report to the Agency for Healthcare Research and Quality, Baker et al.10 call for the adoption of a standard health care team taxonomy based on existing team theory and research. Yet, Baker notes that medical specialties differ considerably, and thus, a single taxonomy would likely not generalize across all types of medical teams. The purpose of this article is to provide a basic teamwork heuristic and taxonomy of critical teamwork processes to standardize and advance EM-based team training research by providing conceptual coherence (i.e., a common language and a means to focus effort) and generalizability for future studies. First, we define categories of teams pertinent to EM. Second, we propose the adoption of a temporally based model of team processes that conceptualizes the dynamic nature of teams.8 Third, we describe a theoretically based team process taxonomy in an EM context. Finally, we make recommendations regarding the incorporation of this model and taxonomy in EM team training, assessment, and future research. THE NATURE OF TEAMS AND TEAMWORK Over 50 years of psychological research demonstrates that teams collectively possessing high levels of expertise, resources, and commitment to success can still fail without strong teamwork skills.11 Current literature goes a step further to state that a team’s processes are

ª 2008 by the Society for Academic Emergency Medicine doi: 10.1111/j.1553-2712.2008.00250.x

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critical to its effectiveness.12 This is especially true for ‘‘action teams’’ such as air crews, military command and control, and emergency medical teams, where specialized experts have to coordinate their knowledge, effort, and skills in uncertain, time-pressured situations. In this section, we define work teams, interdisciplinary action teams (IATs), and the nature of teamwork and task work extant in the psychology literature. Work teams 1) consist of two or more individuals; 2) share a commitment to common goals; 3) are part of a larger organizational system; 4) have differentiated skill sets, roles, and responsibilities; 5) make decisions and coordinate tasks to accomplish goals; and 6) exhibit interdependencies with respect to workflow, goals, and outcomes.12–15 Within EM, interdisciplinary work teams function under conditions of high stress and unpredictability for brief, limited periods of time. As such, EM work teams are characterized as IATs, defined as teams that combine members with specialized skill sets in situations that require coordinated response to unexpected events.16 In an emergency department (ED), IATs include nurses and physicians assigned to a particular area or subset of patients for the duration of a shift, as well as ‘‘trauma teams’’ or ‘‘code teams,’’ formed for the specific purpose of caring for one particular patient. Team processes are at the core of what makes IATs effective and ultimately successful.18 Processes are interactions among team members that combine collective resources to resolve (or fail to resolve) task demands. Processes therefore form the basis of team competencies, or the knowledge, skills, and attitudes (KSAs) that are critical to effective team performance. Task work represents what teams have to do and forms the basis of assigned roles and team goals. Team tasks also determine the workflow structure and need for coordination to accomplish team goals. In other words, processes facilitate task work to achieve team goals. A DYNAMIC MODEL OF TEAM EFFECTIVENESS The dominant framework of team effectiveness is based on an input-process-output (I-P-O) model illustrated in Figure 1.17 In this framework, inputs refer to the characteristics possessed by team members, such as their abilities and past experiences, as well as available organizational resources. Processes, as stated above, are the interdependent acts and behaviors that convert inputs to outputs, which include team performance, task outcomes, and characteristics of team member satisfaction.12 This is a cyclical process, where outputs from

Figure 1. I-P-O model of team performance cycle. I-PO = input-process-output.

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one team episode feedback as inputs into the next. In this way, teams learn and adapt from one episode to the next. Example: An ad hoc EM team is formed to resuscitate a patient. The team brings expertise in airway management, intravenous (IV) placement, and advanced cardiac life support algorithms. Two team members know each other well, enjoy working together, and are motivated to be part of this team. This knowledge and expertise can be considered inputs into the team cycle. Once the resuscitation begins, the team communicates orders, assigns roles, and monitors the patient’s status (team processes). Success or failure in any one of these areas impacts the outputs of the cycle, namely, the patient’s condition and the willingness of team members to remain part of the team. If the patient had a difficult intubation, where the team leader had to ‘‘step in’’ and take over, this could impact not only the patient’s health (hypoxia and poor ventilation), but also the motivation of the junior team member to remain a part of the team and the willingness of the team leader to allow a junior individual to attempt intubations in the future. These outputs become inputs the next time members of this team interact. The I-P-O model provides a useful framework for organizing the factors that may facilitate or inhibit team effectiveness. One limitation is that it treats team processes, which are conceptually dynamic, as static.18 A more contemporary theory focuses on the dynamic aspects of team tasks as cycles of action, necessitating distinct teamwork processes.19 This perspective is well illustrated by Marks et al.,8 who developed a temporal model of team processes and performance, in which different team processes are critical, depending on the task work required (Figure 2). Episodes where the demand for task work is high are characterized by action processes that facilitate accomplishing team goals. These episodes of high activity are separated by periods where teams execute transition processes that facilitate planning and reflection. Underlying both action and transition processes are interpersonal factors that influence all team activities. Considerable

Figure 2. Temporal model of teamwork.

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evidence supports this temporally based process model. A recent meta-analysis of teamwork processes demonstrates that the teamwork processes described by Marks et al. have a positive relationship with team performance and member satisfaction.20 These processes generate observable behaviors that can be practiced and measured, thus making them most pertinent to simulation-based training (SBT) and assessment. We propose that EM use this framework as a template to construct a teamwork taxonomy that 1) is supported by team theory and research, 2) reflects the dynamic nature of teamwork in EM, and 3) incorporates mechanisms and roles important to EM.

DEVELOPING A TEAM PROCESSES TAXONOMY

AN EM TEAMWORK MODEL Teamwork occurs over time and varies depending on the task work and the level of team activity required. We propose that there are three phases of activity for EM teams: planning, action, and reflection. Teams execute different processes and require different KSAs during different phases to accomplish their overall goals (Figure 3). Team processes that revolve around activity monitoring and coordination are more important and more likely to occur during action phases, whereas processes involving preparation and feedback are more important during planning and reflection phases, respectively. This differs slightly from Marks et al.,8 who combine both planning and reflection processes into one phase. We conceptualize planning (i.e., setting goals, identifying appropriate task strategies prior to task engagement) and reflection (i.e., diagnosing areas for improvement) as distinct processes.21,22 In addition, there are interpersonal processes and supporting mechanisms that occur throughout a team cycle that do not map strictly onto any one activity phase.8,9,23,24 Taken together, these overarching processes and mechanisms, along with the three phases of activity, help to structure an EM teamwork taxonomy. In the sections below, we identify the components of this taxonomy and provide a clinical example.

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TOWARD A DEFINITION OF TEAMWORK IN EM

The need to be inclusive yet practical is one of the challenges in developing any taxonomy. While Marks et al. provide a useful model, it is not all-encompassing and could be strengthened with more practical team skills. In a recent report, Salas et al.24 describe five core processes, leadership, team orientation, adaptability, mutual performance monitoring, and back-up behavior, that they believe have the greatest impact on team effectiveness. Labeled the ‘‘big five,’’ these teamwork components reflect an extensive literature search to identify variables most critical to the success of interdependent teams, such as those present in EM. Salas et al. further proposes that these ‘‘big five’’ processes require integrating certain coordinating mechanisms to be maximally effective. These coordinating mechanisms, however, are not in and of themselves processes, because they do not describe team member interaction.8,25 There is considerable value in both the taxonomy of Marks et al.8 and the ‘‘big five’’ of Salas et al.24,25 In Table 1, we outline a taxonomy for the processes and mechanisms that comprise the desired team KSAs for EM. We describe them in detail and provide an EMbased team event to illustrate the application and importance of the different processes during different phases of team performance (Figure 4). PLANNING AND PREPARATION PROCESSES Planning processes occur between action phases and describe team behaviors, focused on preparation for task accomplishment in a subsequent engagement.8 There are three major planning processes: mission analysis (MA), goal specification (GS), and strategy formulation (SF). Classically, these processes are described as occurring off-line, during planning meetings or strategy sessions. In EDs, planning processes occur formally just before or during change of shift, but also throughout shifts as demands and resources change. In each case, rapidly assimilating information and planning

Figure 3. EM team process model. EM = emergency medicine; I-P-O = input-process-output.


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Table 1 EM Team Taxonomy Planning processes Mission analysis Goal specification Strategy formulation Action processes Monitoring progress toward goals Systems monitoring and adaptation Back-up behavior Coordination Reflection processes Debriefing Supporting mechanisms Leadership Team cognition Closed-loop communication EM = emergency medicine.

appropriate task strategies are critical for team adaptation and, therefore, team success. Mission Analysis (MA) Mission analysis involves the interpretation and evaluation of the team’s tasks, as well as resources and environmental conditions.26 MA requires teams to identify tasks and assess the tools they have to accomplish it. This may include verbalizing individual expertise, identifying available equipment, or noting ED capacity and staffing issues. Teams that fail to conduct a MA, regardless of how brief, are likely to have difficulty adapting to changing conditions and tend to function in a purely reactive mode.8 Goal Specification (GS) Goal specification refers to activities surrounding the identification and prioritization of team goals that are aligned with the team’s overall mission.8 In EM this

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could involve identifying and fulfilling needed roles, such as airway management, IV access management, code leader, etc. Identifying and fulfilling roles can also occur during action phases, especially when unanticipated issues arise. Poorly conceptualized goals (i.e., failure to clearly articulate goals and their priorities) can lead to confusion among team members, inadequate concentration of effort and resources in areas of high priority, and lack of a shared understanding of the team’s purpose.27 Strategy Formulation (SF) Strategy formulation refers to developing alternative courses of action for goal accomplishment. In more stable teams, this type of contingency planning is done in advance and results in a ‘‘Plan B.’’28 EM teams utilize contingency planning in the form of failed airway algorithms, hospital disaster protocols, and surge capacity plans. Probably more important to emergency teams is the ability to immediately react to an unanticipated event or change in patient condition by altering the current treatment plan or protocol. This reactive SF contributes to team adaptability, or the ability to recognize deviations from expected patient responses, and adjust clinical treatment and management of patients accordingly.29 Example: At the beginning of an overnight shift, a trauma code is called in by an emergency medical services unit. The call is taken by the telemetry nurse and is relayed to the attending physician and charge nurse. The report states that a middle-aged man was in a high-speed motorcycle crash. He has multiple bruises and abrasions, and his vital signs are stable. The nurse and physician briefly discuss the report and elect to ‘‘call a trauma code,’’ which activates the trauma team and further EM personnel (MA). On arrival, the entire health care team is informed of the patient’s reported condition. They

Figure 4. EM team model with processes and supporting mechanisms. EM = emergency medicine; EMS = emergency medical services.

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are also informed that the ultrasound machine is not working, thus delineating specific resource issues (MA). The team appoints a leader and assigns pertinent nursing and physician roles that are not implicit in the team’s previously established protocol (GS). A specific role is created to contact radiology, since the ultrasound machine is broken (GS). The team decides to ‘‘hold’’ the CT scanner for the trauma patient in case there is evidence of thoracoabdominal trauma and the patient is stable; however, if the patient is unstable they will take the patient to the operating room (SF). This is discussed briefly with the charge nurse, who reports no conflicting resource needs with regard to the CT scanner (MA). The patient arrives. He has significantly decompensated and is now noted to be hemodynamically unstable and unresponsive. The team rapidly adapts to the new situation and defines their goals and priorities: 1) stabilize airway, 2) begin fluid resuscitation and order transfusion, 3) conduct a primary survey for injuries, and 4) prepare patient for the operating room if no improvement (MA, GS). These activities may seem routine and therefore less important than other team activities. However, failing to attend to planning processes places the team at a significant disadvantage. Failure to communicate a known equipment issue may create future problems. The fact that EM teams have very little time to plan does not make it less important. Improved and frequent planning discussions were shown to facilitate better team performance in the MedTeams study.30 The so-called ‘‘swift socialization’’ that occurs in EM teams is an important area of future study to identify techniques that maximize the team’s ability to perform these functions. ACTION PROCESSES Action processes describe four types of behaviors that occur as teams work toward accomplishing its task work and objectives: 1) monitoring progress toward goals (MP), 2) systems monitoring and adaptation (SMA), 3) back-up behavior (BB), and 4) coordination (Co). Monitoring Progress (MP) Monitoring progress toward goals is defined as observing, interpreting, and communicating system (patient) information to determine how the team is progressing toward its ultimate goal.9,31 This is akin to providing the team real-time feedback so that any discrepancies between current team status and team objectives are recognized and remediated.32 Such activities are crucial for the detection of latent errors. Systems Monitoring and Adaptation (SMA) Systems monitoring and adaptation refers to the team’s ability to track its resources and the environmental conditions as they relate to the task (patient care).24,26 Teams

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must monitor their own personnel and equipment as well as any information generated within the team. In addition, the team must remain cognizant of the environmental conditions (ED census, staffing, etc.) relevant to the team and develop new plans as needed.32 Back-up Behavior (BB) Back-up behavior is defined as anticipating team members’ needs, balancing work loads, assisting or managing other team member’s tasks when needed, and correcting errors or oversights.24,33 Good BB is seen when teams communicate workload distribution problems and shift responsibilities as needed. This requires all team members to be aware of role assignments so that appropriate assistance can be delivered when and where needed. Failure to monitor team members and provide appropriate back-up leaves the entire team performance susceptible to a point of weakness or overload.8 Coordination (Co) Coordination simply refers to the sequence and timing of activities.21,26 This is highly relevant for EM teams that must multitask and direct multiple activities in a multidisciplinary fashion. Because many patient care tasks are interdependent (an IV must be started to administer medications, etc.), Co is a major activity of EM teams and, as noted in several reports, a primary area of team breakdown.34 Example: The team has now recognized that the patient is more critical than reported and adjusts their roles and tasks appropriately. The charge nurse calls the anesthesia team to alert them that a potential surgical patient is in the ED (SMA, SF). The team member assigned to manage the patient’s airway begins to evaluate and report the need for intubation. An additional team member is assigned to assist with the intubation (BB). The team leader reports that the patient will be intubated (Co). Meanwhile, the individual assigned to monitor vital signs reports that the patient is becoming more hypotensive (MP). The EM senior resident is told by a nurse that another one of her patients is becoming more ill. The resident communicates with the team leader that she will need to leave the team if her other patient becomes more unstable (SMA). The team leader assesses his resources and communicates to the team that the resident will be leaving the team and her roles will be assumed by another team member (BB). It is communicated to the team leader that the intubation has been accomplished and is felt to be successful based on physical exam. The intubation team members note that significant trauma to the chest wall was initially missed (MP, Co). The patient continues to decompensate, and the team leader elects to take the patient straight to the operating room rather than continue with the assessment and treatment in the ED. The patient is taken to the operating room by the surgical team. An anesthesiologist is prepped and waiting, having been alerted by the charge nurse.


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This scenario is quite typical, but as described is quite simplistic. There are, in fact, multiple events imbedded within a single patient encounter. The patient intubation and surrounding activity is an episode with a brief planning, action, and reflective phase. When considered this way, care of a complex patient becomes a series of overlapping episodes requiring processes from multiple different phases. REFLECTION PROCESS Debriefing Team debriefing in this situation refers to team leader– or team member–driven critical evaluation of the events that transpired during the team’s performance.21 Debriefing should be focused on team processes, rather than overall performance and outcomes.10 By recognizing errors and so-called ‘‘near misses,’’ teams can learn a great deal during debriefing. Reassessing the team’s performance also assists with evaluating both individual and team competencies and can give valuable information regarding the need for further training.35 Example: The team gathers briefly after the patient leaves for the operating room. The course of events is reviewed by the team with the EM attending facilitating the discussion. The nurse notes that the chest wall trauma was not initially reported to her until after the intubation. The attending notes that he too was unaware of this finding until late in the patient’s care. The senior resident reports that she did examine the patient and noted the finding, but was preoccupied with setting up for the intubation, then had to leave the room so the information was not relayed. The nurse reports that she must have gotten the ‘‘normal’’ exam from one of the other team members. A junior team member reports that he gave a report of ‘‘normal’’ for the neck exam, and that may have been the point of confusion. The EM attending reinforces the need for strong communication techniques and for all information to pass through the team leader and to be shared with all team members. It is noted that the team leader for the event was from the surgical team and that individual is not currently present. The team notes several performance strengths, including their ability to adapt to a change in patient status. The EM attending agrees, and issues regarding communication of physical findings are tabled until a later review with the trauma team.

SUPPORTING MECHANISMS Leadership Team leadership is critical to developing and utilizing team skills and processes to enhance team effectiveness.24,36 Leader actions are dynamic to support team members based on the experience level of the team and the critical nature of the situation.19 Thus, leaders guide the setting of team goals and roles, monitor team devel-

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opment and performance, intervene as needed, and guide teams to diagnose areas of deficiency through debriefing.22 In the above scenario, leadership skills and behaviors are present throughout. The team leader assigned roles during the planning phase, coordinated care, and monitored resource availability when a team member left the group and facilitated team debriefing after the performance episode. Team Cognition (TC) Team cognition refers to the team’s shared understanding of goals, tasks, individual expertise, and information.25 This concept incorporates the idea of ‘‘shared mental models,’’ where members individually possess the same information about team goals, tasks, and the environment.9,37 TC expands this definition slightly to recognize the fact that in IATs, where members possess specialized skills, every team member does not require an identical knowledge and information base.25 In fact, exact replication of mental models across all team members would likely decrease variety in team member perspectives and ideas and therefore limit team adaptablility.18 Within the team-training literature, the concepts of compatible mental models and transactive memory have been used to explain how teams distribute, access, and utilize knowledge.38 TC enhances team communication and processes and thereby effective team performance. Developing TC is an important role for team leaders.39 In the scenario, a failure in TC led to a delayed diagnosis of chest trauma. The individual who identified the physical findings became overwhelmed with other tasks and did not communicate the information. As a result, the team did not appropriately prioritize treatment. Closed-loop Communication (CLC) Closed-loop communication is a mechanism whereby the sender initiates a message, the receiver interprets and acknowledges the message, and the sender follows up to ensure the message was received as intended.40 CLC directly addresses failed reception or interpretation of information. Communication is often hindered in critical medical cases due to the stress and complexity of the situation.25 In interdisciplinary teams, individual bias based on specialty and role can alter interpretation of communicated information.41 CLC has been postulated to improve information exchange and decrease communication-related errors. In the above scenario, the nurse transcribed incorrect information regarding the patient’s physical exam. CLC could have prevented the error and might have alerted the team that a chest exam had not been reported. This would have reminded the senior resident to report her findings or have alerted someone else to repeat the exam (BB). IMPLICATIONS FOR SIMULATION-BASED TRAINING (SBT) AND ASSESSMENT Effectively utilizing SBT to enhance medical team performance requires that both the design of scenario

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events and the measurement tools link directly to training goals and desired team competencies.42 SBT programs target teamwork processes that are not clearly defined and have not been shown to improve team effectiveness.43 The taxonomy provided here delineates team processes that have empirical evidence linking them to team performance. While it is likely that there are EM-specific team processes that have not been identified in the literature, those listed above are broad enough in scope to reflect critical aspects of medical team performance, yet are narrow and specific enough to facilitate the development of valid metrics. The EM teamwork model we propose is based on a temporal team process framework that has been validated. By incorporating both the team processes and the temporal model into training and assessment design, EM researchers can build solid team training platforms that generate meaningful research data, while enhancing the effectiveness of interdisciplinary medical teams (Figure 5). Below we offer nine key recommendations to guide the implementation of this taxonomy into routine SBT. Additionally, we offer eight key research points that should serve to direct future research into team processes and performance. RECOMMENDATIONS • Prior to SBT design, a training needs analysis should be conducted (i.e., significant errors and sentinel events should be identified, deconstructed, and then mapped onto the team process taxonomy) to ensure that there are direct links between critical training needs and training design. • Selection of educational methodology (lecture, computer simulation, high-fidelity simulation) should be based on team processes and mechanisms being trained, as well as the level of the learner (i.e., mov-

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ing from declarative knowledge to more complex procedural skills necessitates higher level simulation). SBT should focus on team processes rather than task work when training at a team level. Scenario design should consider the temporal nature of team performance and recognize that team behaviors will be elicited during specific phases of the team cycle. Scenarios should be designed to elicit and reinforce the team processes that are the target of the training by embedding ‘‘triggers’’ designed to initiate team activity. Measurement tools should link directly to defined team processes to allow the collection of meaningful data. The taxonomy should be transparent and universal. Learners, educators, practitioners, and health care management should adopt these terms and use them accurately to facilitate the transfer of learned behavior to the clinical arena. During debriefing, team performance and behavior should be deconstructed and linked to specific team processes, thus allowing team members to understand the importance of specific team-level interactions. Debriefing should allow team members to discuss ways in which emergency teams can adapt and incorporate these processes into fast-paced, rapidly changing team activities.

FUTURE RESEARCH • Determine methods of incorporating effective team training into EM graduate and continuing medical education. • Develop training tools to target specific team competencies.

Figure 5. Role of taxonomy in simulation training and assessment.


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• Define and model the ‘‘swift socialization’’ planning that occurs within ad hoc emergency medical teams. • Identify and define specialty-specific team processes that have not been identified in other domains. • Identify a system to accurately capture the performance of emergency medical teams in the clinical setting. • Develop a simulation-based research platform to study the effects of different training interventions, team composition, and environmental factors on team performance. • Expand on the above-described EM teamwork model to accurately reflect the level of multitasking and prioritizing that occurs during care of multiple complex patients. • Expand on the current literature to better understand the role of EPs as team leaders and elucidate how this changes depending on the expertise of the team and the academic focus of the department.

SUMMARY Carefully designed and implemented SBT is a powerful educational tool that can improve team effectiveness and performance. By clearly outlining the processes and mechanisms that have been linked to team effectiveness, we provide a common taxonomy for EM teams that will drive further training and research endeavors. Furthermore, we list recommendations for team training and assessment that will guide clinicians and researchers in EM team performance.

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