Table 3 Proposed Taxonomy of Non-Technical Skills and Team Constructs for Ad Hoc Team Resuscitation
Nontechnical Skill/Construct Definition [f/% of studies from this review reporting on construct] | Considerations for Prehospital Ad Hoc Resuscitation Teams | Selected citations |
|---|---|---|
Leadership The ability to develop team structure, maintain direction, and coordinate team activities. Leaders occupy a central role in facilitating communication with particular emphasis on developing and maintaining team situational awareness [47/77%] | Leadership is a subcategory of teamwork and central to teams’ success Members should maintain congruent and shared beliefs about which members are leaders Leadership may be fluid, transitioning between team members or distributed across numerous team members as task demands change or as team composition evolves Leaders often play a key role in team stress management, trust, and psychological safety, and maintaining a positive atmosphere Threats: 1.Ambiguous leader identity. 2. Leader performing technical interventions resulting in task fixation/loss of situational awareness | |
Communication Verbal and non-verbal exchange of information. May occur within the team and between team and environment (e.g., patient, bystanders). Whereas communication may be task oriented or social in nature, communication is often studied in relation to the extent it develops situational awareness, performing mutual performance monitoring, and task delegation [49/80%] | Literature supports closed-loop communication (e.g., direction-verification-confirmation-acknowledgement, follow up once task complete) Leader communication is directed at maintaining situational awareness and task delegation, follower communication is directed at closing loop and volunteering information that will foster team situational awareness Communication effectiveness is increased when team member names are used and through direct delegation Graded assertiveness (e.g., Concern-Uncomfortable-Safety) model for patient safety is a means to overcome hierarchical barriers Threats: 1. Excessive/redundant information exchange. 2. Failure to use common language. 3. Cultural or hierarchical barriers resulting in indirect language and incomplete or inaccurate information sharing. 4. Environmental barriers and distractions | [5, 6, 20, 24, 28, 29, 32, 35, 42, 44,45,46, 50, 51, 57, 66, 75] |
Teamwork A complex set of interactions amongst individuals who work adaptively and interdependently to achieve a common goal. Classically considered a broad construct and inclusive of other constructs such as leadership, followership, mutual performance monitoring, backup behaviour, adaptability, and team orientation [47/77%] | Patient safety literature in resuscitation has supported a transition from vertical integration, to a more horizontal structure that favours team input. Resuscitation teams feature characteristics of distributed cognition whereby working memory and pattern matching are greater than that of any individual member Resuscitation team composition is often fluid, with dynamic team member turnover, changes in or distributed leadership, and the presence of sub-teams with specialized tasks (e.g., airway team, compression team) Threats: 1. Ad hoc teams must unite under immense time pressure in conditions of significant complexity, as such team behaviours and structure are vulnerable to failure. 2. Vertical integration and hierarchy have oppressive impact on follower performance | |
Briefing/Planning Briefing: A targeted communication prior to commencing team resuscitation in which salient details of the impending resuscitation are delivered and a team plan of action and role assignment is determined via collaborative decision-making Planning: Updates occur throughout team activity via regular situation reports [10/16%] | Briefing is attributed to enhanced team mental models, decreased role ambiguity, and is associated with error reduction A four-step model is proposed to facilitate rapid prebriefing, these roles include: 1) what do we know?; 2) what do we expect? (plan A); 3) what will we change? (plan B); 4) role assignment Planning behaviours include updating of the initial briefing through regular “pauses” or “situation reports” and facilitates improved situational awareness and adaptive behaviours Threats: 1. Ad hoc resuscitation teams often assemble while the event is ongoing, eliminating the opportunity for prebriefing | |
Resource Management The assignment of team members and equipment to tasks in a way that is responsive to variable supply and demand of these assets. Requires the assessment of provider capacity/skill level and utilizing team members in such a way that optimizes their contribution. [21/34%] | Responsive to fluctuating resource support and demands (e.g., conflicting priorities, fatigue) Requires clear, direct, and specific task assignment Threats: Mass casualty response and prehospital resuscitation often modifies resource management requirements and situates individual patient resuscitation within a larger team environment. The construct applied to this circumstance is that of a multi-team system. In a multi-team system, team composition is highly reactive to fluctuating demands of broader incident priorities | |
Stress/Fatigue Management Individual and team-based approaches to maintaining team performance by mitigating the adverse effects associated with stress and fatigue [11/18%] | Maladaptive stress response is associated with dysfunctions including degraded shared mental models, decreased performance in decision making, altered situational awareness, and impaired team function Fatigue is associated with deficits in resource management, teamwork, situational awareness, and decision making Leadership, mutual performance monitoring, backup behaviour, communication, are suggested as mechanisms to foster optimal team orientation, which can combat the detrimental effects of acute stress and fatigue | |
Followership Who follows whom, the traits and characteristics exhibited by those in a following position, the process by which team members occupy a following role, and the influence that followers hold within the team [3/5%] | Refers to traits of resuscitation team members not assigned or fulfilling a leadership position. The corollary to leadership, an acknowledgement that most team members are not leaders but nevertheless exhibit characteristics that have the capacity to significantly impact team performance Followership research in resuscitation is limited, but there is increasing recognition that the earlier focus on hierarchical teams – with the resulting focus on leader behaviour – contrasts with recognition for the role of follower behaviours | |
Debriefing A facilitated reflective process performed upon conclusion of team resuscitation efforts for the purpose of examining elements of optimal and suboptimal performance. [7/11%] | Debriefing allows opportunity for immediate feedback and fosters a culture of trust and support, facilitating improved team behaviours Threats: 1. The migration of the resuscitation environment from prehospital scene to emergency department functions as a barrier to effective whole-team debriefing. 2. Vertical team structure, lack of trust, and lack of psychological safety are all identified to negatively affect team member contribution to debriefing | |
Decision Making A dynamic team process of interpreting data collected from the patient and environment to develop a working diagnosis and determine a course of action [19/31%] | Resuscitation decision making is often recognition-primed, with little space for deliberative decision making The concept of “distributed cognition” is proposed as a mechanism to describe team decision-making or “team mind” whereby the leader functions as the central executive and team members as evidence gatherers and treatment agents Studies identify that working memory and pattern matching are improved when decisions are made as a collective in resuscitation teams (e.g., collectives have a larger library of past experiences to contrast with the current situation) | |
Situational Awareness/Team Situational Awareness Process of observing and interpreting ongoing clinical events and environments. Three steps: (1) perception of elements within a dynamic environment or system (e.g., patient); (2) comprehending the meaning associated with these observations; and (3) projecting these findings to support anticipation and response to future events. Evident at the individual level and at the team level [28/46%] | Situational awareness is foundational to decision-making and guides team coordination, communication, and behaviours Pre-briefings and intra-response situation reports (“Here’s what I see, this is what I think it means, and this is where I think we’re headed”) supports accurate team situational awareness and provides opportunity for correction Optimized by: (1) orientation at the beginning of the task; (2) maintenance during task and after disruption/change in environment; (3) recovery and reorientation after degradation Follower push communication (providing salient information without being asked) and communication of situational awareness is highly correlated with optimal team performance Threats: Task fixation, scene complexity, entrenched hierarchy/interagency silos, and stressful team environment can limit individual situational awareness while also limiting or eliminating voluntary team member contribution and thus diminish accuracy of team situational awareness | |
Mental Readiness Developing psychological skills for individuals and teams to regulate their mental state during performance. Attaining optimal arousal state during moments when demand nears or exceeds resources [3/5%] | Behaviours associated with the maintenance of an ideal performance state of arousal include: controlled or “tactical” breathing, self-talk, mental rehearsal, and activities that foster optimal team orientation such as prebriefings and maintaining mutual trust Stress inoculation training, mental practice, and overlearning are three training techniques that are associated with enhanced psychological skills for optimizing performance in acute stress environments An important foundational component of stress management | |
Adaptive Behaviours A team’s ability to anticipate and modify their structure and behaviours in response to dynamic changes in their patient’s clinical presentation and the environment. These behaviours are highly integrated with other NTS constructs including shared mental models, situational awareness, decision making, and debriefing [6/10%] | Based upon 4 adaptation phases: (1) situation assessment; (2) plan formulation; (3) plan execution; (4) team learning By virtue of understanding each team member’s role in relation to one another, teams with a strong team mental model have the greatest capacity for adaptive behaviour Optimizing team situational awareness through regular situation reports allows teams to more accurately and proactively predict dynamic changes resulting in more effective adaptive behaviours | |
Shared Mental Model Mental models reflect team members’ understanding of the team objectives, structures, and members’ roles within the team. Sharedness reflects the extent that members’ models are similar across the group [13/23%] | Shared mental models enable members to coordinate and anticipate one-another’s actions, even with limited discussion Other constructs from this review are known to support the strength of shared mental models, including orienting members as a team, backup behaviour between members, situational awareness, and effective leadership Associated with higher frequency of communicating and updating situational awareness Threats: Ad hoc and intersectoral teams may have a limited shared understanding of their team and tasks |