of effective teams:
Salas proposed a model for five key dimensions of
Team leadership, involves not only task coordination and planning, but
development of the team, motivation and establishing a positive atmosphere.
monitoring which monitoring requires sufficient understanding of the
environment to enable monitoring of other team members to allow identification
of lapses or task overload.
Backup behavior, which requires sufficient understanding of others’ tasks to
enable supportive actions to be taken by team members, such as redistribution
of workload or support.
which enables a team to respond to changes in the environment and change the
plan for patient management.
Team orientation, which is the willingness to take other’s ideas and perspectives
into account and a belief that the team’s goals, which should be aligned with
what is best for the patient, are more important than an individual’s goals.
These are coordinated by
the underpinning mechanisms of mutual trust, closed-loop communication and
shared mental models.
To achieve these five
dimensions of effective teams, members of the team must respect and trust
each other in order to give and receive feedback on their performance, must
have good communication skills to accurately convey information
and must have a shared mental model.
Shared mental models
lead to a common understanding of the situation, the plan for treatment, and
the roles and tasks of the individuals in the team.
A shared mental model
enables anticipation of other’s needs, identifying changes in the clinical
situation and adjusting strategies as needed.
Without a shared mental
model, the different members of the team cannot fully contribute to
problem solving and decision making,
requirement for developing a shared mental model, and for effective team
performance, is sharing of information between team members.
sharing: a challenge for healthcare teams
Mazzocco et al. found that
teams who shared information about the patient less frequently at the start of
a surgical case and at the handover post-surgery had more than double the risk
of surgical complications than teams that shared such information frequently.
Observers of postoperative handovers found that much critical information (eg,
allergies or intraoperative problems) was not communicated from OR doctors to
There is also evidence
suggesting that specific techniques to improve information sharing can improve
clinical management, such as, in the high acuity setting, declaring an
sharing information about a crisis with the team28 or ‘thinking aloud’—verbalizing
observations and decision-making processes to the team to share your mental
The failures in
information sharing described above, so critical to effective team communication
and safe patient care, are sequelae of educational, psychological and
attention has been paid to doctor–patient communication in the undergraduate
medical curriculum, less is being done to train medical students on how to
communicate with other health professionals.
groups have different expectations concerning the content, structure and
timing of information transfer, and may not understand the role and priorities
of other groups.
Education for health
professionals remains largely discipline-specific with minimal interaction
between healthcare disciplines.
Training occurs largely within
professional ‘silos’, and few healthcare providers receive specific training in
Such separation of
disciplines and differences in education does little to address understanding
of others roles, responsibilities or priorities, and may contribute to problems
when interprofessional teamwork is required.
While development of a
professional identity as a doctor or a nurse is a key part of professional
education, there are some downsides. Psychologically, the distinction between
and ‘outgroup’ is strong38 39 and social identity theory explains that members
of a professional group (eg, medicine, nursing or the allied health
professions) tend to see the attributes of their
group as positive and those of other groups as less desirable.
Certain types of people
are also attracted to certain professions and specialties,43 strengthening this
allegiances can lead to tensions when different professional groups have
different expectations about how things should be done.
A further psychological
barrier to effective communication is the hierarchical structure in healthcare.
Although senior staff
are happy to use commands, less senior staff may not feel they can challenge
decisions or offer suggestions or alternative diagnoses and so may conceal
The physical geography
of a hospital and the geographical location of patients within the hospital can
affect the efficient scheduling activities of the patient care team, such as
ward rounds, or
scheduled meetings to discuss patient management plans.
These geographical and
organisational factors act as barriers to information sharing, with junior
doctors describing the difficulties in coordinating patient care across
multiple wards, with multiple different staff, relying on ‘opportunistic
meetings’ with nurses or physiotherapists to convey important information.
Likewise, nurses, who may know the patient
best, may not be present when key decisions are made about their patient. The
reality is that staff may know what sort of communication is required, but the
environment is not conducive to actually doing this. Additionally, different
clinical areas may use different forms or incompatible software, making it
difficult to access or interpret information. The interface between electronic
patient notes in primary and secondary care is one example.
During my residency
training program, as an orthopedic resident, I was in one of the rotations in a
non-consultant based hospital. The junior staff are separated from the senior
staff in management of patients. It was
difficult to get help from senior staff due to lack of communication and the
system. Also, there was no job description or privilege for the resident.
The whole rotation was
stressful in terms of patient management and follow up. Also, it was stressful
from educational point of view. I heard about some cases which were mismanaged
due to lack of supervision or senior involvement, especially in the theater or
critical areas. And when disaster happens, the junior level will receive the
I would consider that
experience as a nut island effect.
Teach effective communication strategies
methods of communication, such as ‘SBAR’ handovers, can improve patient
Train teams together
Teams that work together
should train together. Training that includes all members of the team improves
Train teams using simulation
Using simulation is a
safe way to practice new communication techniques, and it increases
Define inclusive teams
Redefine the team of
healthcare professionals from a collection of disciplines to a cohesive whole
with common goals.
Create democratic teams
Each member of the team
should feel valued; creating flat hierarchies encourages open team
Support teamwork with protocols and procedures
Use procedures that
encourage information sharing among the whole team, such as checklists,
briefings and IT solutions.
Develop an organizational culture supporting healthcare teams
Senior champions and
department heads must recognize the imperative of interprofessional
collaboration for safety.
to improve communication
Stepping back from and taking an overview of the situation, the
health professional who is leading the team calls the attention of the team and
provides an update of the situation, the plan and invites suggestions.
This three-step strategy involves; the sender directs the
instruction to the intended receiver, using their name where possible; the
receiver confirms what was communicated as a check on hearing and understanding
the instruction, seeking clarification if required; the sender verifying that
the message has been received and correctly interpreted.
Structured information transmission(SBAR/ISBAR).
This is a widely used acronym to help structure verbal at handover
or patient referral. The original version (SBAR) has been expanded in some
reports to ISBAR, starting with Identify yourself: Identify ?Situation?Background?Assessment?Recommendation.
Simple templates for summarizing
important patient information at handover.
Graded assertion (PACE).
Escalating concern (Probe, Alert, Challenge, Emergency).
? Elucidate the
association between patient harm or inefficient care, and failures in teamwork
? Develop and evaluate interventions to improve teamwork and
communication with safe and effective patient care as the primary outcome.
? Translational research to
embed evidence-based teamwork and communication interventions in clinical and organisational