1. Harkins, Deborah MBA, BSN, RN, CCRN

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It has been a relatively quiet evening in the emergency department (ED) when the trauma radio perks up to announce a new patient.

Figure. Deborah Hark... - Click to enlarge in new windowFigure. Deborah Harkins, MBA, BSN, RN, CCRN

Inbound via helicopter is a 41-year-old male unrestrained driver involved in a roll-over car crash at 23:30. The patient has a blood pressure of 90/56, a heart rate of 138 and is now receiving his fourth unit of blood. The patient was complaining of abdominal pain, has a deformed right leg, unstable pelvis, and large scalp laceration. Estimated time of arrival is 10 minutes.


Resources are mobilized. The trauma bay is prepared. Appropriate people converge: radiology, respiratory therapy, nursing, emergency physicians, and trauma physicians. The patient arrives in shock with unstable vital signs. The group hovers around the patient and moves like a well-oiled machine. Nursing staff attach the patient to the monitor and insert various catheters. An emergency doctor prepares to place an endotracheal tube, whereas respiratory therapy sets up the ventilator. Trauma surgeons insert a chest tube and use an ultrasound to assess bleeding in the abdomen. Radiology obtains films and the operating room staff communicate that they are ready for the patient, whereas the intensive care unit prepares a bed in anticipation. Total elapsed time is 20 minutes. Trauma is a team sport. All team members have specialty skills and decision processes they bring to the table. Although they have individual purpose and accountability, they work in concert to pursue a common goal and outcome. Each member of the team is equally important. There is communication, interdependence, mutual respect, and trust. There is complete synergy. The whole is greater than the sum of its parts. If an individual on the team drops the ball, it may be a matter of life or death despite the extraordinary efforts of all the other players.


And, this is how we would like all trauma resuscitations to go, but too often, we find ourselves in incongruent communication, chaos, and tension. Certainly, we could learn a thing or two from Dogbert:


In the unlikely event that your job generates any real work, fob it off on your underlings by having them form "self-managed teams." That's an elegant way of saying they do your job in addition to their own. This is a bit like teaching the cows to milk themselves, but it's possible if they're flexible.1(p92)


For a team to be effective, the underlying efforts must be driven by group results, not individuals. Members must be able to check their egos at the door and put aside personal agendas in favor of team goals.


Why do some teams function better than others? By its very nature, trauma care engenders teamwork. Each cog in the multidisciplinary wheel must contribute expertise, but even this does not ensure that all will go well. So, how do we teach teamwork? What is the makeup of a good team? How can we assimilate team concepts into the healthcare culture? What are the defining characteristics?


First, let us step away from healthcare for a moment and broadly define a team. A group is not a team, is not a committee, and is not a task force. How easy it is to get caught up in "lingo"!! Many firms, today, propagate groups as teams. A working group is defined as a small set of individuals who are aware of each other, interact with one another, and who have a sense of themselves together as a unit.2 Their performance is a function of what each member does as an individual because members do not work interdependently and do not share responsibility for each other's results. A team includes all the characteristics of a working group but adds several others, including members working interdependently and being jointly accountable for performance goals. The difference is subtle, but vital.


We often see organizations, including business schools or even grade schools, trying to emulate and integrate teamwork concepts. Teamwork happens on a daily basis from McDonald's to the boardroom to the operating room to the orchestra pit. Are there distinctions and opportunities that must be in place to define a team and set the stage for successful outcome? Absolutely. Are teams always the best tool for the job? No. Simple, routine, or highly formalized work is not well suited for teams.3 There are occasions that warrant individual attention and will yield better results. Teams, on the other hand, tend to rise to the occasion in the face of creating, assessing, and implementing innovative practice, solving broad cross-functional workplace problems, and changing the way work is accomplished. As the adage goes, "two heads (or three or four) are better than one" or put another way, "no one in the room is as smart as everyone in the room!!"


The Society of Trauma Nurses has incorporated teamwork concepts into the advanced trauma care for nurses course with the use of a MedTeams video.4 Inevitably, this portion of the course stimulates much discussion and just as many questions from participants. We all struggle to understand the complexities of team interaction and how to improve situations. And, we believe teamwork can be taught and learned.


The MedTeams concept has its roots in the military with a training program titled "Crew Resource Management." This resource management program was developed following the analysis of 3 plane crashes, which revealed inadequate coordination of team members. These errors caused many people to lose their lives. To combat human mistakes, the military devised a program to focus on crew-level training (as opposed to individual) to instill a culture of safe and efficient flight operations and communication. MedTeams has translated many of these concepts to the world of healthcare and paved the way to teach teamwork skills in an organized fashion. The curriculum focus is on a number of key constructs such as the following:


1. clarify the medical situation;


2. use a callback system (once a team member is asked to do something, the team member echoes the task back to clarify receipt of information);


3. support a culture of challenge (an opportunity to validate decisions by anyone on the team);


4. delegate tasks to a specific person rather than the room; and


5. communicate the plan to the entire team.



In a multicenter trial, 9 teaching and community hospital EDs participated in a team training curriculum to assess the effects on team behavior and overall performance in the ED. A curriculum with classroom instruction and workplace integration focused on 48 concrete teamwork behaviors and utilized MedTeams interventions. The core concepts focused on processes of teamwork, the specific coordinating actions that caregivers must take with one another to work as an effective team.5 This is in stark contrast to the traditional focus on caregiver roles and tasks. In addition, steps were taken to inculcate the teamwork model into the environment, for example, incorporating scrubs of different colors to identify staff or eliminating barriers in the physical surroundings to promote information exchange between nurses and physicians. Results showed that observed clinical errors were significantly reduced from 30.9% to 4.4% and staff attitudes toward teamwork improved. Lessons learned included the need for continuous support from upper-level management as well as establishing an ongoing system of coaching and mentoring to critique teamwork performance. In addition, authors identified that ongoing training and refresher courses are a must to maintain a teamwork culture.


To deal with the ever-changing, complex patient care environment, Salas et al suggest a set of core team principles. "These principles are an important set of reminders, given the elusive and dynamic nature of teamwork. These can serve as guides for practical applications or interventions such as team training."6


1. Team leadership matters.


2. Team members must have clear roles and responsibilities.


3. Shared understanding of the task, teammates, and objectives goes a long way.


4. Take time to develop a discipline of pre-brief-performance-debrief.


5. Team affects matter.


6. Clinical expertise is necessary but insufficient for patient safety[horizontal ellipsis]. Cooperation, communication, and coordination skills matter.


7. Teams must have clear and valued visions.


8. Learning from mistakes, self-correction, and adaptability are the hallmarks of high-performance teams.



Trauma and many other specialties are weak in the area of debrief. This is not inherent to our day-to-day practice. Often, trauma team members are busy caring for a sick patient and there is no defined time to debrief and learn from situations. Sure, we carry out performance improvement-trauma is very mature in those processes-and some centers even videotape ED resuscitations. But often, only certain types of cases are reviewed. The process neither provides rigorous, consistent feedback to caregivers regarding integration of teamwork concepts nor does it distill and analyze the barriers to teamwork. A lack of debrief and feedback does not allow for continuous improvement and learning. So, how can we accomplish this task and ingrain teamwork behaviors?


Patient simulations have long been an avenue to teach clinical skills in a safe environment while providing time for feedback and the ability to learn from mistakes. More recently, simulation-based education centers have adapted a new role to teach multidisciplinary teamwork, enhance communication, and improve patient safety. Advantages to simulation include the following:


1. provides alternative to live patients scenarios and avoids potential complications that can ensue;


2. allows for repetition and practice;


3. educators can create and control clinical scenarios from start to finish;


4. permits consistent development of case circumstances, thereby encouraging comparison of different team approaches;


5. audio and video capabilities provide review, analysis, and debrief opportunities; and


6. promotes identification and acknowledgment of mistakes and a culture of learning through error.



This growing field has even defined a new profession-simulation-based medical educator-with professional qualifications that are multidisciplinary in nature and based on the growing experience of medical educators in training students and professionals.


Defining the profession is essential to create academic environments in which professionals will be trained to develop and implement new programs, accompanied by research and assessment.7


Simulation provides an important alternative to enhancing team-based learning because it addresses the challenges and feedback that remain difficult to manage in live patient scenarios. Simulation centers, however, are expensive with manikin costs of up to $40,000, dedicated space requirements, staff infrastructure, and allotted nonproductive time for a number of clinicians (usually 5-10) to participate in team-based scenarios.


Trauma has been at the forefront in leading team-based resuscitations. Teamwork is the nature of trauma care. If we are able to incorporate more of the methods mentioned here, we will improve the attitudes toward teamwork and begin to reinforce behavior that fosters a shift in the culture of care. This requires investment and buy-in from the health system and senior leadership to be successful. Our challenge as trauma care providers is taking teamwork to the next level.


I thank Dr David Lindquist, Assistant Professor in the Department of Emergency Medicine at Brown Medical School, for taking time to discuss the many aspects of teamwork training and provide references and insight into the advanced Rhode Island Hospital Medical Simulation Center at Brown University. Dr Lindquist is a true advocate for teamwork fundamentals and shared responsibilities. His efforts to instill these concepts into practice are admirable!!




1. Adams S. Dogbert's Top Secret Management Handbook. New York: Harper; 1996:92. [Context Link]


2. Schein E. Organizational Psychology. Englewood Cliffs, NJ: Prentice-Hall Inc., 1980:145. [Context Link]


3. Wetton D, Cameron K. Developing Management Skills. Reading, MA: Addison-Wesley; 1998:424. [Context Link]


4. MedTeams. Accessed April 12, 2009. [Context Link]


5. Morey JC, Simon R, Jay GD, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Serv Res. 2002;37(6):1153-1581. [Context Link]


6. Salas E, Rosen M, King H. Managing teams managing crisis: principles of teamwork to improve patient safety in the emergency room and beyond. Theor Issues Ergon Sci. 2007;8(5):381-394. [Context Link]


7. Zin A, Ben-David S, Zin M. Simulation based medical education: an opportunity to learn from errors. Med Teacher. 2005;27(3):193-199. [Context Link]