Being a team member/leader and team dynamics in ED (2024)

by Munawar Farooq & Bret Nicks

Introduction

Emergency care worldwide has organizational and regional nuance, mainly due to differences in healthcare systems, infrastructure, resources, and history. However, the team’s value proposition remains critical for success in all emergency departments. Over the past several decades, it has become evident that teams and teamwork can positively impact many aspects of the care environment and the engagement of those serving there. When we consider the myriad challenges impeding quality decision-making in the emergency department (ED), such as a lack of time, evolving information, chaotic environment, limited resources, and constant interruptions, amongst others, having a dedicated team can make a significant difference.

While the concept of a team is not new, our understanding of the value proposition of a team and the attributes of effective teams continues to evolve. For many of us in medicine, working in a group is expected. However, there are distinct differences between working in a group and being part of a team. What differentiates a team from a group is the commitment to a common purpose, shared desired outcomes, collaborative and complementary approach, value team over self, and shared accountability. A team’s foundation develops from those that collaborate around a shared goal. However, successful Emergency Medicine (EM) teams require a broader understanding of the essential attributes, processes, and expectations needed for a highly variable, chaotic, intellectually challenging environment dedicated to exceptional patient care. For these reasons and many others, EM epitomizes the ideal of team sports in healthcare.

Psychology of Team

Team dynamics are the learned, unconscious psychological forces influencing a team’s behavior and performance. Organizational culture and departmental culture significantly affect team dynamics. Further influencing factors include the nature of the work, the work environment, work relationships within and across teams within the department, the level of perceived support, and the work effort itself.[1] Recognizing the challenging environment of acute and emergency medicine, awareness of and creating an integrated and positive team dynamic is essential. High-functioning teams demonstrate better clinical outcomes, increased team retention, increased wellness, higher resiliency, and better comparative financials.

High Performing Team Characteristics

Characteristics of successful teams and team members have been studied extensively in various professions ranging historically from the aviation industry to more modern companies like Google. [2] The aviation industry mandates that the flight and cabin crew work together as a team using standard operating procedures (SOPs) and formal training to facilitate teamwork and communication. They recognize that cognitive and psychological stressors can lead to human errors that can occur in high-stakes environments.

Looking at a very different workplace, researchers at Google asked what makes a (Google) team effective. While they anticipated finding the mix of those on the team to be the most influential on the team’s success, they found that the way team members interacted with each other mattered more than the composite of the team [1]. While competency requirements exist in EM and other clinically-based teams, much of Google’s findings apply. They identified five characteristics that promoted effective teams: psychological safety, dependability, structure, clarity, meaning, and impact (Figure 1).

Figure 1: Characteristics of Highly Functioning Teams.

Adopted from Rozovsky J. The five keys to a successful Google team. 2015. URL:
https://rework.withgoogle.com/blog/five-keys-to-a-successful-google-team/

Although EM is not Google, recognize that the foundation of all highly effective teams remains the same: trust. In the 5 Dysfunctions of a Team, Lencioni states that you cannot have a successful team without trust. Further, with a lack of trust, team members fear engagement in healthy conflict, essential to reaching better decisions and team member commitment. Only committed team members can hold each other accountable so that the team remains focused on collective goals (Figure 2).

Figure 2: Lencioni, Patrick. The five dysfunctions of a team. London: Wiley, 2002

In emergency medicine (and perhaps medicine in general), metrics and outcomes are commonly the focus of many teams. While quality, safety, and administrative outcomes are essential, one should recognize that top performance of these outcomes flows from teams built on trust, embracing conflict, commitment to a common goal, and shared accountability. When these are in place, quality metrics follow. Addressing team dysfunctions takes work. It requires a desire for positive change, courage, and creating team alignment.

Further, emergency medicine teams are dynamic interdisciplinary teams working in a constantly changing environment with highly fluid teams of junior and senior emergency physicians, nurses, other specialists, students, residents, and other medical assistants. With so many variable team inputs, solidifying the departmental culture and creating the expectation for and practice of highly functional teams helps ensure that any patient receives safe and efficient healthcare, meeting high-quality standards without fail regardless of date, time, and acuity of presentation.

Literature on high-performing teams across multiple professions supports these and additional common characteristics. Dr Tim Baker, in his book ‘Winning Teams’ presents eight characteristics of Winning Teams, as shown in Figure 3.

Figure 3: Adopted with permission Winning Teams, Dr. Tim Baker. Used with copyright permission from DBOS. 8 Key Characteristics of a High-Performing Team | by DBOS AU | Medium

Fulfilling this model, our emergency room teams are diverse but flexible. We adopt safe and effective working procedures like cognitive aids and structured communication tools. We aspire to achieve a shared goal of efficient and safe patient care. We create teams that build trust and mutual respect through transparent communication and clear leadership. We accomplish this by continuously learning and practicing together the necessary clinical skills and critical human factors.

Team development and its success are predicated on a supportive culture that recognizes a just cause. For high-performing organizations, that culture is well-established across all departments and levels. Regardless, organizational culture is simply what you see when you watch and experience the service provided. It comprises a complex pattern of values, expectations, ideas, attitudes, and behaviors around a shared goal.

Effective Emergency Team Leadership

One key challenging but rewarding role of the emergency physician is to orchestrate and lead diverse teams in a relatively stressful and unpredictable environment. While this may represent one of the major attractions of the emergency physician, it can be daunting for some. For a junior physician, it is essential to identify good leadership attributes early and apply them continuously, as it benefits the team and a leader’s clinical navigation during resuscitation. Something can be learned from every member of an interprofessional resuscitation team. Observing how they serve as role models and clinical leaders in any situation and how they interact with colleagues, patients, and families provides a basis for personal growth and reflection.

Advanced life support simulation studies identified better outcome metrics (higher quality cardiopulmonary resuscitation with better technical performance, shorter pre-shock pauses, with lower total hands-off ratio, and shorter time to first shock) with teams having leaders with more experience and refined leadership attributes. [3] Although variability exists with healthcare leader experience, having a high-performing team enhances team dynamics and outcomes. Regardless, effective team leaders must embrace and demonstrate the following leadership elements:

Understand the team value proposition and roles of its members
Manage well in challenging and changing situations
Effectively communicate
Embrace mutual accountability and responsibility
Set specific goals while persevering to achieve them
Balance individual tasks and promote teamwork
Build solid connections and relationships
Demonstrate adaptive learning from their experiences.

It is important to note that most of these attributes are not related to knowledge and skills commonly taught in medical schools but rather experientially or intentionally developed emotional intelligence skills. Developing and deploying these elements can positively influence everyday tasks performed by emergency physicians, such as:

Organize the team and resources to maximize performance
Articulate clear goals with delegation of tasks
Make decisions through the collective input of members
Empower team members to speak up and challenge the leader when appropriate, using group norms to guide behavior
Actively promote and facilitate good team processes
Skillfully prevent and resolve any conflict

Although historically called soft skills or abstract skills, data would suggest that these critical leadership skills are as necessary as clinical competencies. Effective leaders not only work on their clinical and content competence but also on emotional intelligence, communication skills, and performance under pressure.

The Team Player

What makes a team player exceptional? When you think about your current team(s), are they made up of ideal team players? If not, what are you doing about it?

While exceptional team leaders can navigate the professional nuances of their team members, the team’s success is often limited by the leader’s capacity and by the attributes of those team members. High-performing teams are far more multiplicative rather than the simple sum of individual member performances. How we identify future team members or invest time and effort into developing current team members impacts not only outcomes but also influences the quality and capacity of the team.

Often, we hire team members based on their clinical competencies, educational accomplishments, and career success. However, moving beyond competence to team and organizational cultural alignment is essential as we look more closely at developing high-performing teams. Leaders must identify and employ people with three traits that all good team players share: humility, hunger, and smart people (interpersonal intelligence). In his book, “The Ideal Team Player,” Lencioni recommends considering aligning the essential virtues of a team player into three characteristics:

Humble (not arrogant or ego-centric; team-focused)
Hungry (great work ethic; never settling for the minimum)
Smart (skilled in emotional intelligence and people skills)

The ideal team player must have all three characteristics to be a trusted and proficient team member. Assessing teams requires self-reflection regarding these three traits, a conscious desire, and a focused effort to improve. Awareness and growth in this area catalyze individual and team success. When only one or two of these attributes are present, team leaders must consider the value proposition of developing these team members or identifying other opportunities that might be better for that team member.

Key Principles of Teamwork

In addition to discussing the psychology of teams, attributes of high-performing teams, effective team leadership, and ideal team players, further studies have looked at systematic approaches to creating a culture of teamwork within healthcare. TeamSTEPPS, an educational program about teamwork, highlights the fundamental principles of an effective team structure, clear communication process, transforming leadership, situational awareness, and mutual support. [2]

Leaders use Delegation, Pre-Brief and Debrief, and Group Huddles in effective teams to clarify team goals, roles, and expectations. Both team leaders and members maintain situational awareness, cross-monitor each other, and provide constructive feedback. Everyone uses structured communication tools like SBAR (Situation, Background, Assessment, Recommendation), Checking Back, Advocacy, and Gradual Assertiveness to communicate clearly and deliver the safest and best possible care.

Practical Tips to Improve Teamwork

Understanding the attributes of high-performing teams, team leaders, and team members considering the challenges of emergency medicine is foundational to change. However, identifying practical applications that begin to create change and further support culture is essential. [5] Below are some typical applications that have been suggested in the literature and through clinical experience:

Department awareness: Before you start working in a new department, visit, observe, identify the culture, and ask yourself how you can be a catalyst.
Bring your clinical competence and communicate medical decision-making with your team.
Developing empathy in daily challenges requires intentionally understanding another’s perspective, avoiding early judgment, recognizing inherent emotions, and responding genuinely to that emotion. (Brene Brown)
Understand and set role expectations while understanding how your personal attributes influence how you perceive your role.
Huddle first, then get started. Know your team – names and roles. Set expectations for team goals and find opportunities to engage and communicate in person with colleagues throughout the shift.
Consider the patient and their family an essential and valuable team member. The ‘nothing about me without me’ principle applies to everyone, including the patients and staff.
Lend a helping hand. Look for such opportunities and do not wait for the request.
Self-reflection increases continuous learning and improvement. Make it a regular practice regardless of the outcome or situation.
In any resuscitation or other emergency team management situation, follow the principles of clear roles, closed-loop communication, task focus, situational awareness, and the courage to speak up if required for patient or staff safety.
Listen actively by paying attention to non-verbal clues and perspectives while being aware of your own. Listen to understand – do not listen to respond.
Avoid negatively inferred language that feigns responsibility and creates blame or division. This rapidly erodes teamwork and a supportive culture.
Handoffs matter. Align your approach and expectations, as this directly impacts patient and team outcomes.
Offer compliments and appreciation genuinely and frequently. Recognize a job well done with gratitude. It reinforces positive effort and builds team rapport.
Build relationships outside the work environment when feasible. Know your colleagues through their interests, values, goals, achievements, and challenges.
Advocate for patient safety. Learn how to challenge a team member or leader if there is any concern for patient safety. Use a structured tool like “CUS” (Figure 4) or simply state, “I have a concern.”
Never think you are alone. Help is always available. Working in the emergency department is not easy – recognize it. If you need assistance, clinically or personally, ask.

Figure 4: CUS, graded assertiveness tool. Source: TeamSTEPPS. https://www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html

Case Scenario Application of Team Dynamics

Let us apply all the above learning to a resuscitation scenario and understand how a resuscitation team works. You are part of a resuscitation team when EMS encodes that they are bringing a 10-year-old boy whose scooter was hit by a car. The suspected injuries include a head injury and a possible right thigh injury. The trauma resuscitation team manages the patient very well through the following teamwork processes:

Pre-arrival

Assigned roles. The assigned team leader knows the team members’ strengths, limitations, and expectations. Every member acknowledges their assigned role and any concerns or needs they may have. Doing so before the patient’s arrival helps mitigate positional limitations during the resuscitation. Any members outside this team are also informed as required according to local resources, e.g. Radiographer, Pediatric Surgeons, Orthopedics, etc.
Environment and equipment are prepared with enough space to work around. Airway and resuscitation equipment, confirmed at the beginning of the shift, is assessed based on any specified checklists and procedures.

Post Arrival

On arrival of EMS, handover is taken using pre-defined handover tools or processes with prehospital teams. The noise and distractions are kept to a minimum to optimize patient care information handoff and prompt transfer.
The team leader directs care with the team – and, when possible, stands at the foot of the bed to maintain situational awareness and monitor the team’s performance.
Team members perform assigned roles while maintaining situational awareness, monitoring the patient and teammates, and reporting back.
Clear and respectful closed-loop communication. Team leaders direct requests to every member using their names, and team members acknowledge the understanding of the task by repeating back and then announcing the completion of the task.
The team leader frequently shares ongoing medical decision-making with the team throughout the resuscitation by describing the situation and plan. For example, after completion of the primary survey, the team leader announces, “It appears that the child has an isolated head injury. Let us aim to intubate this patient and transport him to a CT scan within the next 15 minutes”. This provides directional clarity and offers an opportunity for feedback.
Teams use cognitive aids like checklists to prevent any medical errors. In contrast, the team leader maintains an open, respectful, and empowering environment where every member can challenge and raise patient safety concerns. Team members use graded assertiveness tools like ‘CUS’ to raise their concerns.
A culture of vulnerability and trustworthiness is maintained when team leaders or team members express when they are unsure of something and freely ask for help or a second opinion. Before any significant high-risk decision, the team leader shares the medical decision-making rationale and plan with the team.
Updating or briefing new members from other teams by the team leader or a designated member allows for clarity of ongoing care and consultative expectations. Recognize the emergency department is your home, but that may not be true for others.
After resuscitation, a hot debrief is performed with the team to express objective gratitude, provide compliments, discuss what went well, and identify areas for improvement. Critical issues should be addressed in a more formal debrief, especially if future application is intended.

As mentioned throughout this chapter, the benefits of developing a high-performing team in the emergency department are myriad. It will improve departmental morale and greatly influence the quality of care provided, create mission alignment, foster resiliency, and attract exceptional team members. Table 1 presents additional benefits of effective teamwork [6].

Organizational benefits	Team benefits	Patient benefits	Benefits to team members
Reduced time and costs of hospitalization	Improved coordination of care	Enhanced satisfaction with care	Enhanced job satisfaction
Reduction in unexpected admissions	Efficient use of healthcare services	Acceptance of treatment	Greater role clarity
Services are better accessible to patients.	Enhanced communication and professional diversity	Improved health outcomes and quality of care, reduced medical errors	Enhanced well-being

Table 1: The benefits of effective teamwork

Summary

Successful teamwork is challenging but worthwhile. Trust represents the foundation of all successful teams. They also embrace a shared common purpose and a dedication to quality in an environment where team members work together, communicate effectively, anticipate and meet each other’s demands, and inspire confidence, resulting in coordinated collective action. For many, the phrase, ‘teamwork can make the dream work,’ resonates with them. It is an uphill climb. It starts with trust. It requires courage. And it requires effort. If the dream is high-quality patient care in a safe and respectful department, start with your team.

Authors

Munawar FAROOQ

Dr. Munawar Farooq, with qualifications including MBBS, FCPS (Pak), MRCS (UK), FACEM (Australia), and a Pg. Dip. in Medical Toxicology from Cardiff University, UK, is currently an Assistant Professor of Emergency Medicine at CMHS, UAEU. His prior roles include Consultant in Emergency Medicine in Canberra, Australia, and Doha, Qatar, Clinical Lecturer at Australian National University (ANU) in Canberra, ACT Australia, and Honorary Senior Lecturer in MSc Resuscitation at Queen Mary University London, UK. His special interests are in resuscitation medicine, toxicology, trauma, and medical education. His research focuses on detecting deteriorating patients, early warning scores, oxygen delivery device requirements in COVID outbreak, on-floor low fidelity simulations, and Leadership Training. In medical education, he is particularly interested in teaching leadership skills, Emotional Intelligence, and Human factors.

Bret NICKS

Bret Nicks, MD, MHA is an emergency physician that embraces the breadth of our specialty. He is a Professor and Executive Vice Chair of Emergency Medicine at Wake Forest University School of Medicine. He is the past president of the North Carolina College of Emergency Medicine. He served as the Chief Medical Officer of the award-winning Wake Forest Baptist Davie Medical Center. Dr. Nicks served as the founding Associate Dean for the Wake Forest Office of Global Health. He has lived, practiced, and led in many resource austere locations globally, although calls the academic tertiary care emergency department his home. He is passionate about, consults and lectures on the interface of clinical quality, leadership and team culture – and is dedicated to developing EM leaders for the future of our specialty and the transformation of healthcare. He loves anything outdoors, enjoys blogging on various life and leadership topics; http://www.bretnicksmd.com/blog, and recently published his first book.

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References

Rice MM. Strategies for clinical team building: the importance of teams in medicine. Emergency Department Leadership and Management: Best Principles and Practice. 2014 Nov 27:47
Rozovsky, Julia. “The five keys to a successful Google team. 2015.” URL: https://rework. withgoogle. com/blog/five-keys-to-a-successful-google-team (2015).
Yeung JH, Ong GJ, Davies RP, Gao F, Perkins GD. Factors affecting team leadership skills and their relationship with quality of cardiopulmonary resuscitation. Crit Care Med. 2012;40(9):2617-2621. doi: 10.1097/CCM.0b013e3182591fda
Clapper TC, Kong M. TeamSTEPPS®: The patient safety tool that needs to be implemented. Clinical Simulation Nursing. 2012;8(8):367-373
Vazquez CE. Successful work cultures: recommendations for leaders in healthcare. Leadersh Health Serv (Bradf Engl). 2019;32(2):296-308. doi:10.1108/LHS-08-2018-0038
Babiker A, El Husseini M, Al Nemri A, et al. Health care professional development: Working as a team to improve patient care. Sudan J Paediatr. 2014;14(2):9-16.

Free online resources for further self-learning

CanadiEM Frontline Primer, Emergency Department Culture 101. https://canadiem.org/canadiem-frontline-primer-emergency-department-culture-101/
Rozovsky J. The five keys to a successful Google team. 2015. URL: https://rework.withgoogle.com/blog/five-keys-to-a-successful-google-team/
Lencioni P. The 5 Dysfunctions of a Team. Teamwork 5 Dysfunctions | The Table Group
Pocket Guide: TeamSTEPPS https://www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html
Podcast; Dr. Randy Sorge with Dr. Ryan Stanton, Teamwork makes the dream work – Team Dynamics in the ED. https://music.amazon.com/podcasts/816785e7-0c23-47c0-96f4-38017c4b11ba/episodes/6a12c8fd-71f1-4b64-8274-ea72e4189fe3/acep-frontline—emergency-medicine-teamwork-makes-the-dream-work—team-dynamics-in-the-ed

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.