Background

Time-sensitive emergency situations are common in intensive care units (ICUs). The intensive care team must be able to perform multiple interventions and make critical decisions in order to improve physical- and mental well-being for patients [1]. In the management of emergencies a multi-professional team approach is beneficial for efficiency as well as safety [1,2,3]. Nevertheless, coordination and communication can be challenging as the staff involved often have different professions, traditions and hierarchical status [4]. Emergency team members often favor a standardized approach using algorithms and protocols in managing emergency situations [5]. However, team members find it problematic to apply a structured approach when co-workers in ad hoc teams do not share the same knowledge, skills and experiences [4,5,6]. Although a variety of studies have demonstrated that team process behaviors, such as communication and coordination, contribute to effectiveness of clinical performance [7], there seem to be factors other than knowledge, skills, and attitude that influence team performance [8]. One of these factors could be the density of social ties within the team, which has been demonstrated to have positive influence on quality of treatment in emergency departments [9]. However, how social ties influence teamwork and performance has received limited attention in the context of clinical emergencies.

Social network theory provides one theoretical framework to help understand the influence of social ties within emergency team members. In social network theory, it is the relationships between individuals that are of interest rather than the specific attributes of individuals (e.g. knowledge and skills). Each individual in a network is considered as a ‘node’ in a complex interaction of ties between individuals [10]. These social ties may be expressive or instrumental. Expressive ties are those that relate to friendship and affective components whereas instrumental ties are those that arise in a professional setting [11]. In areas outside medical education, social network theory has been used to explain students’ academic performance based on strength of their interpersonal ties as well as to examine how employees interact with each other in the workplace [12]. When applied to health professions education, social network theory may enable a more collectivistic and holistic perspective to the analysis of teamwork instead of the traditional individualistic perspective focusing on individual team members’ competencies and performance.

The aim of this study was to explore staff’s perceptions of teamwork and performance in clinical emergencies with focus on the role of social ties within the team. To minimize the potential influence that context and team members’ knowledge and experience have on team performance [6], we chose the context of intensive care for our study as intensive care staff in general are experienced professionals familiar with managing clinical emergencies, such as resuscitation or difficult airway management.

The research question was: How do intensive care staff perceive the role of social ties in teamwork and performance?

Methods

Design

The study was explorative, using a constructivist, thematic analysis approach for data collection and analysis [13]. Data collection was performed in two iterations. We started with group interviews to gain a broader understanding of how task, context and social ties between team members affect their perceptions about team performance. Based on these initial findings, the interview guide was revised and we conducted individual in-depth interviews to gain a richer understanding of the role of social ties for teamwork in emergency settings. Consistent with a theoretical sampling approach, data collection continued until saturation of themes was achieved [14]. When saturation was met the full dataset was coded according to the final themes.

Setting, time and participants

The interviewees were a purposive sample of intensive care nurses and intensive care physicians employed in two ICUs in Greater Copenhagen.

The interview guide

Semi-structured interviews were performed. The first interview guide aimed to explore how factors related to people, task, and context affected aspects of teamwork and performance. The second interview guide, developed from the findings in the initial analysis, aimed at further exploring the role of social ties within the team. In our study the term social ties include both expressive ties and instrumental ties [11]. Both interview guides were developed in two steps. First, the project group discussed the content and questions and approved the versions used in the pilot tests. Second, the interview guides were pilot tested with intensive care nurses and physicians to avoid misinterpretation, misunderstanding and leading questions. The interview guides were adjusted according to the findings from these processes. Data from the pilot tests were not included in the final dataset.

Data collection and data analysis

The three group interviews were conducted performing one interview every day 3 days in a row. The interviews were transcribed and the transcripts and the interviewers’ notes were analyzed for emerging patterns and themes related to the research question after each interview. Saturation was meet after three interviews.

A new semi-structured interview guide was developed, and the form was changed to individual interviews, as we wanted to learn more about the expressive ties, which we assumed the interviewees would speak more openly about during individual interviews. Eight individual interviews were conducted, two per day in 4 days over a two-week period. The interviews were transcribed and the transcripts were analyzed for emerging patterns and themes related to the research question after every two interviews. Saturation was met after eight interviews. Data was subsequently analyzed in multiple iterations until theme agreement was achieved. The full dataset was then coded according to the final overall themes using NVivo®.

Results

Interviews

Three group interviews and eight individual interviews were performed. The groups included mixed groups of nurses and physicians and the individual interviews included four nurses and four physicians. The full dataset included interviews with eight intensive care physicians and ten intensive care nurses, Table 1.

Table 1 Participant demographics, including interview method
Full size table

Themes

Four overall themes emerged, Table 2. One related to social ties within the team, the second to team members’ knowledge and experience, the third to team coordination and the fourth to team communication. In the following the interrelated themes are described separately but with the main focus on their complex link to social ties. As this link is our main focus, the theme, social ties within the team, is described first.

Table 2 Selected examples of interview citations. There are four overall themes
Full size table

Social ties within the team

The interviewees emphasized the importance of knowing their co-workers. They described that communication with someone you know is easier, and that if you know your co-worker you tend to be more forgiving and helpful. If the expressive ties were strong, if they liked and trusted a co-worker, it was more likely that they would ask for advice or support, irrespective of profession, tradition and/or hierarchy. The interviewees mentioned that having personal knowledge of someone potentially had the same advantages as knowing someone professionally. Despite the importance of social ties during emergencies, the interviewees stressed that they were “professional enough” to put aside their social preferences. Strengthening of the social ties could be created by repeatedly working together or by simply “drinking coffee together” during a break. Furthermore, their individual perception of a co-worker could be modified by rumors and other co-workers’ opinions and their prior experiences from working together (reputation).

Team member’s knowledge and experience

Team members’ individual knowledge and experience were highly valued by the interviewees and described as important for achieving effective team performance. However, there was a tendency toward nurses wanting a clear, fixed standard, whereas physicians appreciated more adaptable or “flexible” standards. Shared knowledge of specific department routines and protocols including algorithms was highly appreciated, even in situations where the team needed to deviate from the standards. In these situations, social ties helped the interviewees to trust, challenge and/or accept the decisions being made. The interviewees reported that instrumental ties, knowledge of co-workers’ prior experience and/or knowledge, made coordination and communication easier by enabling a more implicit communication and coordination of the teamwork.

Team coordination

The interviewees emphasized the importance of having clearly defined roles. Knowing what to do next was described as reassuring, with potential to reduce cognitive efforts needed and to provide the possibility to pre-plan own tasks. However, the interviewees emphasized implicit coordination as being their preferred coordination style in most situations. Physicians stated that in case they sensed that the nurses were coordinating and performing the appropriate tasks, they would not interfere or explicitly approach the team with information or ask for specific tasks to be done. The interviewees felt that strong social ties within a team made the task distribution easier as knowledge of co-workers contributed with cues for intuitive assessment of skills, knowledge and experience.

The interviewees described the importance of hierarchies in relation to coordination. There were different types of hierarchy, one being flat versus a more top-down type, another being a formal versus an informal type—the formal being based on legal responsibility according to professional status, the informal based on experience and knowledge of department routines. The hierarchy was closely related to how well staff knew each other. When strong social ties were present the hierarchy flattened. The formal hierarchies came into play when staff for some reason sensed uncertainty, which could be related to lack of knowledge of the department’s normal routine or perceived lack of expertise or experience. In addition, the interviewees reported that those they would turn to or trust in a critical situation would be those they knew and liked the best, not necessarily those who were considered the best qualified.

Team communication

Implicit communication was highly valued by staff. Non-verbal communication was appreciated, where staff were able to “sense” what their co-workers were doing or thinking and in which direction they were heading. In teamwork where staff knew their co-workers, explicit communication was perceived as less important. However, explicit communication was necessary when communicating with “unknown”/“new” or inexperienced co-workers or in situations where the team for some reason was losing the sense of direction. Staff reflected on which cues they used to decide when to change from implicit to explicit communication or vice versa, and it seemed to be highly individual, context-dependent and influenced by former experiences with similar cases or co-workers. Hierarchical status, formal or informal, as well as the atmosphere within the team had an influence on which communication style staff preferred. In emergency situations, where team members had strong social ties, the formal hierarchy was less important, which allowed the entire team to ask questions and come up with suggestions regarding the patient care.

Discussion

The four themes and thus the combination of instrumental and expressive ties point in different directions: Social ties within the team emphasize the relational and social character of the group working with each other. Team member’s knowledge and experiences highlights the subject matter expertise of the team members, as perceived by their colleagues. Team coordination foregrounds how the team members used their knowledge about the situation at hand, about processes and guidelines, about what they know (or assume) their colleagues are able and willing to do, and about an overview of what was already done, what is currently done, and what will be done next. Team communication provides some insights into the many ways, how team members use a range of verbal and non-verbal cues to gauge their colleagues’ abilities and professional trustworthiness. In summary, the themes identified might shed some light onto those aspects beyond medical knowledge and skills that impact teamwork and possibly performance.

Staff valued when they knew that co-workers were familiar with the department’s routines and standards. This finding is in line with our earlier study, where former Advanced Life Support (ALS) course participants found it easier to work with co-workers, who also had attended an ALS course [5]. Emphasis on standardization of behavior through routines in coordination processes is common in medicine [14]. Nonetheless, the disadvantage of routines include that they may impede further learning, adaptation and flexibility [15]. This dilemma becomes overt in the interviews as physicians appreciate having adaptable standards, whereas nurses prefer fixed standards. Earlier studies on resuscitation teams have shown that teams with a more explicit communication and coordination style performed better than other teams [16]. However, our findings suggest that implicit and explicit team coordination modes have both advantages and disadvantages. It has been suggested that the coordination and communication modes should be adjusted according to the context [17] and this kind of adjustment is being practiced in some settings [18]. Nevertheless, staff in our study highly valued the implicit communication and coordination style.

Although our data do not explain why staff favored the implicit style there may be several explanations. One is that in order to work implicitly, team members need to have shared cognition of the situation as well as the skills and knowledge to perform the tasks required. Hence, implicit communication and coordination might be a proxy for knowledge and experience. The point here being that it is not the style of communication or coordination that staff value, but the underlying prerequisite for implicit coordination and communication.

The perception of hierarchy was closely related to social ties. In teams with strong ties the hierarchy flattened, whereas the need for a formal hierarchy was emphasized in teams with weaker ties. Nurses called for a clear leader who was willing and able to take responsibility. The wish for a flat hierarchy with a strong leader may seem contradictory. However, one explanation for this paradox could be that when staff members know who they are working with—including their profession, personality and their ability to make decisions—the need for an explicit hierarchy is counterbalanced by shared cognition and the extent of trust and ties in the team. Another explanation could be that there are two hierarchical levels: the social level:” we are all equal”; and the task level:” we do different things” that might influence how teams function differently depending on how strong the ties are within the team.

The interviewees in this study valued that social ties within the team would support their intuition, lower their cognitive efforts and help their decision-making. In clinical emergencies where time is a critical factor, professionals often trade decision accuracy for decision speed because of the resource intensiveness of rational decision-making [19]. The nature of this type of decision-making is therefore to make the best decision in a particular situation and to reassess and change direction if necessary. If an individual is socially related to a co-worker in advance, a benefit could be reducing the cognitive load [20]. However, a possible disadvantage could be being locked in previous assumptions and earlier patterns of interaction [21]. When staff do not know their co-workers, intuitive assumptions must be made of who to trust [22] combined with a sense of who possesses which knowledge and skills [4]. Staff reported that those they would turn to or trust in a critical situation would be those whom they had the strongest expressive ties with - those they knew and liked the best - and not necessarily those they considered the best qualified. This finding is in line with an earlier study where nurses claimed to involve people who they were most comfortable with rather than those who would be the best to solve the problem [23].

Limitations of the study

The study has some limitations. There is an issue related to the applicability in other contexts. Intensive care staff is likely to have prior experience of working together, which might be an important contrast to other emergency settings where multi-professional teams join from different departments ad hoc. Accordingly, the findings might not transfer to other multi-professional team settings. Yet, the fact that social ties, even in the ICU setting, were described as being an important factor influencing teamwork could indicate an even stronger influence in other settings. In this study, we did not explore the relation between social ties and teamwork performance. A recent study of college students showed that a team’s performance was strongly correlated with the teams’ social ties and that the strongest ties explained more of the variance in performance than other factors such as team members’ personalities and competencies [12]. Future studies are needed to explore to what extent strong social ties between team members are associated with better team performance and better patient outcomes within the context of clinical emergencies.

The implication of social ties for instructional strategies during teamwork could be of importance in the design and planning of future team training activities.

Conclusion

Social ties, instrumental as well as expressive, influence teamwork in managing clinical emergencies by affecting the teams’ ability to co-construct knowledge, their task coordination, the need for hierarchy, the degree to which they relied on explicit or implicit communication forms, as well as their ability to promote adaptive behavior.

Social ties may be an important factor to consider in the design of future team training, as well as for work planning and scheduling of team activities during clinical practice.