This study shows that when teamwork was implemented in the clinical setting there was a discrepancy between the planned teamwork process and the actual teamwork behaviors. This was not unexpected, given that the study was done during the early phases of implementation. However, this illustrates the importance of closely monitoring actual behaviors as implementation takes place. By using behavior analysis, this study goes beyond merely describing the extent of such discrepancy by illuminating plausible key behaviors, and the contingences that made these behaviors more likely. This information can be used either to adjust the planned process in accordance with what is practically possible to perform, or to increase the fidelity to the planned process by managing the contingences in order to make the target behaviors more likely to be performed. In the end, these steps are necessary to take before it is reasonable to evaluate the effectiveness of an intervention.
In this study, the revised key behaviors were taking patient history together, meeting in a defined team room, and communicating with team members. When these were performed, the members were able to continuously work together throughout the care episode. Although these behaviors should not be interpreted as generic team behaviors, they may provide an example of how efficient team work can be understood and how the behaviors may be influenced by immediate consequences. The likelihood of the key behaviors was affected by social, personal, and environmental factors. In particular, to increase the likelihood of these three team behaviors, it was important to avoid negative consequences such as having to wait for other team members, having trouble locating each other, and being watched and potentially judged by others. It was also important to be explicit about when team members should interact and communicate.
Taking patient history together has previously been identified as an important part of teamwork . This may allow the team to get a shared situational awareness, defined as an individual's awareness of important care-related information and events . This awareness is particularly important in work situations with high cognitive demands , and has previously been related to high performance in trauma teams . In contrast to when staff works independently in the ED, taking patient history together reduces the need to hand over patient information  as well as the work duplication caused by patients giving their history numerous times to different staff members . However, although taking patient history together may be beneficial from a patient safety perspective and may be more effective in some aspect, it may also be time consuming if one or several of the team members is not able to be engaged in any appropriate task during the activity. More research is needed on the circumstances that make taking patient history contribute to efficient teamwork.
The second key team behavior, meeting in a team room, allowed team members to find each other easily. Besides saving time, this also helped them coordinate their work in a timely manner and reminded them to communicate with each other. Moreover, the team room provided an area where the team members could communicate without patients nearby, which has been suggested as a way to reduce misunderstanding and mistakes . Given that the ED has previously been described as cognitively challenging , the team room may also lessen these cognitive demands.
Given the importance of inter-professional communication within the ED  and given how frequent staff in the ED is involved in communication , the third key behavior, communicating with team members, is not surprising. Effective communication has notoriously been difficult to implement . In the planned teamwork process in this study, the antecedents for communication were not specified. From this follows that although team members did communicate, this communication was frequently delayed and was not always sufficient for effective teamwork. This indicates that besides focusing on communication behaviors as such, it may be equally important to target when communication within the team is essential, e.g. clarify the antecedents for team communication. The most important antecedents for communication we found are similar to those highlighted as particularly important by Risser . Besides providing a cue for the initiation of communication, these can all be seen as means to accomplish a common situational awareness.
In summary, the key team behaviors found in this study were similar to those described in previous studies on communication and team training [15, 18, 34, 35]. However, these studies focus on training, whereas the intervention described here focuses on environmental change. Thus, the fundamental assumption behind the intervention we studied, as well as our methodological approach (i.e. behavior analysis), is that individual behaviors are shaped by the environment in which they appear. Thus, it is assumed that team members have sufficient interpersonal skills to engage in productive team behavior. The importance of adjusting environmental factors, including physical layout and managerial support, to facilitate the implementation of teamwork has been stressed previously [14, 18]. Also, this study focuses on the immediate consequences, which according to theory are most likely to affect behavior. Thereby, it provides an additional perspective to previous studies looking at more general principles for successful implementation of teamwork such as institution-level incentives to train and multi-professional training of staff in their units .
A qualitative study has drawbacks in terms of conclusions on relationships in comparison to a quantitative approach. However, given that the aim of the study was to explore the implementation of teamwork, a qualitative method using direct observation was deemed suitable. It is more objective than self-ratings and has been described as particularly useful to investigate complex interactions between individuals, teams and organizational precursors of teamwork performance . Structured observation scheme, immediate note-taking, parallel observations and clarification questions during observations were used to minimize observer effects such as selective memory effects and observer misconceptions. However, this also made the observers more visible, which may have contributed to the observer-expectancy effect. Although not completely avoidable, this effect was limited by getting the employees accustomed to the observers' presence through pilot observations and by emphasizing that the researchers' interest was not in how well the team members performed but rather on how it was possible to translate the planned process into practice. In this sense, it was not so much the team members who were scrutinized but the implementers.
Observations were made on different weekdays, at different times of the day, on different teams and on team doctors with different levels of experience. Moreover, the observation days differed in terms of patient inflow, workload and number of hospital beds available. Although such factors have been shown to affect the efficiency of teamwork in other studies , it was beyond the scope of this study to investigate the relative influence of such factors. Rather, the goal was to tap into a variety of situations rather than minimize variance.
The analysis of qualitative data may be subject to interpretation bias. However, the use of an analytic model based on a well-established theoretical framework minimizes this risk. Also, the results were validated by key informants, including teamwork implementers and behavior analysis professionals. The results of this study were also fed back to the ED to help them improve future teamwork processes. It also contributed to continuous learning in the ED.
Although the ED in this study is typical in terms of size and work tasks, and the challenges its employees face are similar to those of other EDs in the industrialized world, the single case study design entails limitations in terms of external validity. Hence, this study can tell what might be possible, but not necessarily what is likely, in other settings. However, the results of this study can serve as hypotheses to be tested in other settings using a multiple case study design and could be particularly useful where the implementation of teamwork has been difficult.