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Hence, this interaction requires coordination in order to realize effective clinical team performance Dickinson and McIntyre 1997, Tschan et al.. In other words, without appropriate coor

or the patient’s condition Specifically, on the individual level, relevant factors

include technical competence, heterogeneous knowledge (Rosen et al 2008), high work commitment (Nyssen et al 2003) and a variety of attitudes towards the interpersonal aspect of one’s work and the effects of stress on performance (Flin

et al 2003) On the team level, anaesthetic teams are mostly crew-like (Arrow

et al 2000, Tschan et al 2006) – structured with traditional hierarchies, varying size, sometimes no previous experience as a team and almost no formal training

in teamwork or interaction with one another Finally, the context of anaesthetic

teamwork usually includes highly structured organizations and the necessity to

be attentive to a range of tasks (Leedal and Smith 2007) Tasks are characterized

by routine procedures as well as by rapidly shifting priorities, requiring the handling of high risks where failures can potentially endanger human life Thus, as suggested by functional models of teamwork (Hackman and Morris 1975, Marks

et al 2001, Wittenbaum et al 2004), team and task variants influence clinical

team performance via the interaction of the anaesthetic team members Hence, this interaction requires coordination in order to realize effective clinical team performance (Dickinson and McIntyre 1997, Tschan et al 2006) Besides individual medical skills, experience and patient factors, coordination within the team is a

crucial factor influencing the quality and timeliness of a reaction to unexpected complications This coordination requirement can actually be exacerbated by the crew structure (e.g., MacMillan et al 2004) In other words, without appropriate coordination and effective communication beyond hierarchical constraints, the team interaction could cause process losses which in turn would negatively impact team performance (Marks et al 2002, Steiner 1972) The following section outlines mechanisms of anaesthesia team coordination

Adaptive Coordination in Anaesthesia Teams

Coordination Requirements in Anaesthesia Teams

Performing joint actions requires coordination in the sense of orchestrating the

‘sequence and the timing of interdependent actions’ (Marks et al 2001, p 363)

However, it is not only the coordination of actions but also the coordination of

information (e.g., sharing information regarding a patient’s allergy and discussing

its implication for medication) that is important for clinical performance (Arrow et

al 2000) For example, failure to appropriately communicate relevant information (e.g., patient allergies) to all team members is a frequently reported incident in anaesthesia (Catchpole et al 2008) and problems in information transfer are generally well known in the domain of healthcare (Cook et al 2000, Murff and Bates 2001) This might be due to the fact that in medicine, task-relevant information is often unshared and has to be obtained either from the patient, other team members, written notes or from several monitors in the operating room

These complex information requirements (Hirokawa 1990) pose high demands on team coordination

After having defined what has to be coordinated during team interaction, questions arise on when – during interaction – specific coordination is appropriate

As stated above, anaesthesia is characterized by routine as well as by non-routine procedures in the sense of rapidly shifting priorities In non-routine situations, teams have to manage unexpected and unfamiliar problems potentially endangering the system or outcome (Waller et al 2004) This is a significant point as a non-routine event (NRE) in anaesthesia is by the definition of Weinger and Slagle

(2002, p S59) ‘any event that is perceived by care providers or skilled observers

to be unusual, out-of-the-ordinary, or atypical’ NREs include critical incidents as well as a broad range of events that might not lead to immediate adverse outcomes but nevertheless could be early heralds of post-operative patient outcomes (Oken

et al 2007) A recent survey in anaesthesia has shown that NREs occur in 30.4 per cent of reported cases (Oken et al 2007) By their very nature, NREs are likely

to be ill-defined problems resulting from ambiguous cues and therefore requiring diagnostic effort to define the problem Interestingly, studies from a comparable domain, aviation, showed that non-routine situations require more communication than routine situations (e.g., Orasanu 1993) The question arises as to how these results can be transferred to anaesthesia and how anaesthetic teams can coordinate

actions and information adaptively to routine and non-routine situations.

Adaptive Coordination

Team adaptation means a change in team performance in response to a salient cue leading to a functional outcome for the entire team (Burke et al 2006) For example, teams perform better when their members adapt their role behaviour in response

to unanticipated change (LePine 2003) or when they change leadership behaviour depending upon the level of routine of a situation, the degree of standardization or experience of team members (Künzle et al in press) As Manser and co-authors (2008) pointed out, adaptive coordination occurs on different organizational levels Adaptability has been found to be fundamental to establishing safety (Salas et al 2007b) and has been examined as one of the core components of effective teamwork and a prerequisite for coordination (Salas et al 2005) In our work, we focused on adaptive coordination on the team level and argue that adaptability can be considered a coordination process in and of itself rather than simply a prerequisite to coordination Similar to contingency models of leadership

(e.g., Fiedler 1964), the concept of adaptive coordination implies that different

coordination mechanisms are appropriate in different situations The core idea

of adaptive coordination lies in the dynamic use of coordination mechanisms in accordance with the workload of a given situation (Entin and Serfaty 1999, Grote

et al 2004, Rico et al 2008, Salas et al 2007a, Serfaty and Kleinman 1990) Here, workload describes a relationship between available resources such as information processing capacity and task demands (Byrne et al 1998, Young et al 2008) and

refers to how a given situation is perceived by the person facing the task (Grote

et al 2003) However, it is not only the coordination behaviour in either routine

or non-routine situations which is linked to team performance Rather, it is the adaptive transition from routine to non-routine and vice versa which seems to have significant effects on team performance (Waller et al 2004) The question then arises of how coordination should be changed in the adaptive transitions and by which behavioural means it can be executed

Means of Adaptive Coordination

Within the literature on team coordination, scholars have differentiated between

explicit and implicit coordination mechanisms (Entin and Serfaty 1999, Espinosa

et al 2004, Kolbe and Boos 2009, Grote et al 2003, Wittenbaum et al 1998, Zala-Mezö et al 2009)

Explicit coordination is behaviour that is intentionally used for the

purpose of team coordination and mostly executed by means of verbal

or written communication (Espinosa et al 2004, MacMillan et al 2004, Wittenbaum et al 1998) or by transferring information and resources upon request (Serfaty and Kleinman 1990) and can be used prior to or during team interaction (Wittenbaum et al 1998) In medicine as well as in other

high reliability contexts, a typical form of explicit pre-coordination is standardization of behaviour through rules (Grote et al 2004) During the

interaction, the team process can be explicitly coordinated by mechanisms such as commands or affirmations (Marsch et al 2004) It was found that healthcare teams which successfully treated a cardiac arrest showed more explicit coordination than poorly performing teams (Marsch et al 2004) Explicit coordination can also be used to support group decision processes, for instance by repeating task-relevant information (Kolbe 2007) Explicit coordination is clear and generally understandable but involves communicative effort and time It can be executed by every team member on every hierarchical level or in the sense of shared leadership

Implicit coordination is postulated to be primarily based on shared

cognition and on the anticipations of the actions and needs of the team members (MacMillan et al 2004, Rico et al 2008, Serfaty and Kleinman

1990, Toups and Kerne 2007, Wittenbaum et al 1996) and is also related

to team situation awareness (Manser et al 2008, Salas et al 2005) In a recent study of anaesthesia teams, it was found that transactive memory (knowing who knows what) predicted team members’ perceptions

of team effectiveness, and also affective outcomes such as team identification and job satisfaction (Michinov et al 2008) Compared to explicit coordination, implicit coordination is less time intensive, but is only effective if the team members have not only shared but accurate mental models of the task and the team interaction If one of these two

•

•

requirements is not met, reliance on implicit coordination can be very risky This is in line with the proposals by Wittenbaum et al (1998) who postulated that implicit coordination can be ineffective in complex and interdependent tasks They suggested that the more coordination required (e.g., divergent goals, unequal information distribution, ambiguity of opinions and preferences), the more group members need to coordinate explicitly In fact, explicit coordination has been considered to be a prerequisite of implicit coordination (Orasanu 1993) Given the fact that both implicit and explicit team coordination modes have advantages and disadvantages, the suggestion is that they be used according to the situational demands (Grote et al 2004) However, in medical teams there seems to be an inherent preference for implicitness as the silver bullet of coordination styles and reluctance against being explicit As Heath and colleagues (2002) observed in operating theatres, team members would rather unobtrusively encourage others to perform certain actions with the underlying assumption that explicitly asking them for assistance or consideration was inappropriate or would interrupt activities in which they were already engaged This tacit assumption that ‘the more implicit the communication, the more effective it is’ could be problematic in non-routine situations where explicit coordination is required (Wittenbaum

et al 1998) To ensure that such needs for explicitness are identified, it seems that heedful interrelating can be a useful mechanism of adaptive team coordination

The idea of heedful interrelating was introduced by Weick and Roberts (1993)

and has received considerable attention It includes certain attitudes and behaviours towards the team and the situation in order to act in close alignment with situational and team requirements Being a heedful team member implies being mindful of the team goal and one’s own contribution to it (Dougherty and Takacs 2004) This means that while being heedful, the team members constantly reconsider their own contributions in relation to the team goals (Grommes and Grote 2001, Weick and Roberts 1993) It also means that rather than acting only habitually, team members act purposefully with regard to the joint situation (Dougherty and Takacs 2004) and are well aware of how their actions fit into the overall team goal (Wears and Sutcliff 2003) This form of mindfulness is especially relevant for complex and tightly coupled systems (Vogus and Welbourne 2003) Recent research results have shown that heedful interrelating mediates the relationships of trust in team members and monitoring by team members with future team performance (Bijlsma-Frankema et al 2008) Heedful interrelating consists of three different actions:

(1) the individual contribution by providing own actions, (2) the representation

of the system of joint actions and (3) the final interrelation or subordination of

own actions within the envisaged system (Dougherty and Takacs 2004, Grommes and Grote 2001, Weick and Roberts 1993) Thus, heedful interrelating is related

to the anticipation of the needs of other team members but can be regarded as a

coordination mechanism that goes beyond mere implicit coordination because it can allow team members to identify needs for explicit coordination (Grommes and Grote 2001) For instance, one team member might realize that his or her own or someone else’s actions are not in line with the team goal and therefore the work process has to be reorganized Heedful interrelating also extends team orientation (see Salas et al 2005), because the latter is confined to an attitudinal preference for working with others and enhancing individual performance while working with others Furthermore, heedful interrelating can prevent team members from narrowly following protocols or from over-learned responses (Wears and Sutcliff 2003) and might allow team members the flexibility to speak up when necessary which in turn enhances learning and adaptability (Edmondson 2003), as well as the overall effectiveness of the team

Still, some authors argue that heedful interrelating refers to a way in which behaviour is enacted rather than to the behaviour itself (Druskat and Pescosolido 2002) In line with this, only a few studies have analysed concrete behaviours or communication by which heedful interrelating could be enacted (Cooren 2004, Grommes and Grote 2001, Grote et al 2003, Zala-Mezö et al 2009) A recent study on coordination in anaesthesia teams showed that heedful interrelating occurred more in situations of high workload than in low workload phases (Zala-Mezö et al 2009) Thus, we need to know more about the interplay of explicit and implicit coordination and how heedful interrelating facilitates the adaptive transitions between these coordination modes

Measuring Adaptive Team Coordination Behaviour in Anaesthesia

The objective of our current research on anaesthetic team coordination is to gain a broad perspective of anaesthetic team behaviour coordination during routine and non-routine and relate it to clinical performance This requires detailed analyses of team processes which have proven to be costly in both time and effort However, some authors suggest that not doing these analyses would be even more costly because one would then be forced to forego key information regarding comparative team dynamics and adaptation behaviours (McGrath and Altermatt 2002) As Weingart (1997) concluded, gaining knowledge regarding what anaesthetic teams actually do, how they complete their work and the resulting levels of success increased our understanding of which processes (in this case, coordination) influence group performance, specifically clinical effectiveness However, measuring explicit and implicit team coordination as well as heedful interrelating

is far from being a straightforward endeavour that allows us to draw on a variety

of existing methods Even though implicit team coordination has been analysed experimentally (Wittenbaum et al 1996) and by using self-report measures (Rico

et al 2008), studies on behaviour observations of implicit coordination are rare (Entin and Serfaty 1999, Grote et al 2003, Kolbe 2007, Serfaty et al 1993, Zala-Mezö et al 2009), a fact that might be due to the tacit nature of implicitness

Thus, the necessity to investigate effective and adaptive team coordination and the lack of suitable observation methods led us to develop a taxonomy of explicit and implicit team coordination and heedful interrelating behaviour

Taxonomy of Explicit and Implicit Team Coordination and Heedful Interrelating Behaviour

The taxonomy we developed for our research on adaptive coordination in anaesthesia

teams consists of three main categories: explicit and implicit coordination, heedful

interrelating and other behaviour (Figure 13.1) The main category of explicit and implicit coordination includes two sub-categories: coordination of information exchange and coordination of actions (Arrow et al 2000) Within these

sub-categories we differentiate explicit from implicit coordination mechanism, as shown

in Figure 13.1 The applied taxonomy was developed to measure coordination mechanisms with regard to explicitness, implicitness and heedfulness Its strength lies in the precise yet practical description of behaviour patterns specifically found

in anaesthesia teams

The subcategories were developed in an iterative process based on previous work (Grote and Zala-Mezö 2004, Grote et al 2003, Grote et al 2004), on team coordination literature (Arrow et al 2000, Bowers et al 1998, Espinosa et al

2004, Kolbe 2007, Marks and Panzer 2004, Marsch et al 2004, Rico et al 2008, Salas et al 2005, Serfaty et al 1993, Serfaty and Kleinman 1990, Toups and Kerne

2007, Tschan et al 2006, Wittenbaum et al 1996, Wittenbaum et al 1998), and

on literature regarding heedful interrelating and related concepts (e.g., Bijlsma-Frankema et al 2008, Dougherty and Takacs 2004, Druskat and Pescosolido

2002, Grommes and Grote 2001, Rhee 2006, Toups and Kerne 2007, Vogus and Welbourne 2003, Weick and Roberts 1993) Table 13.1 gives definitions and examples of these coordination mode categories

Data were coded using INTERACT (Mangold 2007), a coding software which allows for marking and coding events within a digitalized video without the need for transcribing the communication In order to analyse the dynamic coordination process and determine whether a certain coordination act is followed by another

coordination act and how long each act lasts, focal sampling (observing the whole group for a specified amount of time such as the induction to anaesthesia) and

continuous coding are required (Bakeman 2000, Bakeman and Gottman 1986,

Martin and Bateson 1993) However, in doing so, the procedure of (1) defining coding units (amount of behaviour that is assigned to one category) and (2) coding these units into categories were confounded because the coding units are defined with reference to the categories (McGrath and Altermatt 2002), a practice which usually impairs the reliability of an observation method (Kolbe 2007) But, since

there were no appropriate unitizing rules for verbal and non-verbal interaction, we

had to define the coding units as utterances or actions by a team member that fit into a single category

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Figure 13.1 A taxonomy of explicit and implicit team coordination and heedful interrelating behaviour

Note: Coding units are here defined as utterances or actions by team members that fit into one category (Bales 1950, Beck and Fisch 2000, Marby

and Attridge 1990) For each act, the actor, the target, and the duration are coded.

Explicit & implicit coordination Heedful Interrelating

Attention focus

on the joint situation

Com-prehension of implications of unfolding events Providing

unsolicited task-relevant action Offers of assistance Indications of satisfaction with fulfilment

of task Monitoring Declaring own needs

Assistance requests

Approval

Planning and procedural questions

Verification questions

Questioning decision

Providing actions upon request

In-process decisions

Initiating actions Making plans

Assigning tasks Giving orders

Coordination

of actions

Provide unsolicited task-relevant information Obtaining unsolicited task-relevant information Listening

Requests for information Providing information upon request Verifying information Acknowledge-ment Summary Questioning information

Explicit Implicit Explicit Implicit

Authoritarian behaviour Silence and action Silence and no action Chatting Technical alarm Talking to patient

Broad boundaries of envisaged system

Focusing on representation

of others

Watching the actions of other team members Verbalising own behaviour

Verbalising interpretation

of a situation Correcting behaviour of other team members

Considering others Teaching others Giving feedback in a positive manner Giving feedback in a negative manner

Considering the future Considering external conditions

Note making

Incom-prehensible communication

Others

Coordination of information exchange

Category Definition example

Explicit coordination of information exchange

team members or questions addressed to the patient.

‘Where’s the defibrillator?’

‘Do you have any allergies?’

Providing information

only in response to direct questions.

‘The defibrillator is right behind you.’

or giving verbal confirmations regarding fulfilled actions.

‘Electrodes are checked.’

indicating one has heard or understood given information.

‘Okay.’

‘Um hm.’

state of affairs or processes ‘We had an asystole in reaction to laryngoscopy

We treated it with atropine and 30 seconds of heart massage.’

doubts about the accuracy or source of information

‘Are you sure he has no allergies?’

fills out the patient’s chart.

Implicit coordination of information exchange

Providing unsolicited

Obtaining unsolicited

task-relevant information Includes actively garnering information without being

asked to do so.

Reading patient’s chart.

attentively listening to another team member or patient with undivided attention.

Explicit coordination of actions

help. ‘Can you help me with this?’

Table 13.1 Definitions and examples for categories

Category Definition example

or instructions. ‘Can you hold this?’‘Give him the fentanyl.’

assigned to team members. ‘I’ll intubate, you watch the monitor.’

non-immediate considerations regarding what should be done and when.

‘When we’ve finished intubation we’ll call for an

OR nurse.’

behaviours which initiate actions (not orders or decisions).

‘We could give him more fentanyl.’

such as defining timing of intubation initiation.

‘We can intubate now.’

Providing actions upon

do so.

After the physician has asked the nurse to administer the fentanyl, the nurse accepts the order and administers the drug.

expresses doubts concerning a decision, order or proposal.

‘Are you sure you want to intubate right now?’

question to make sure they are about to do the right thing.

‘I’ll start now, is that alright?’

‘You’ve already administered the atropine, right?’

Planning and procedural

of action.

‘How much fentanyl do you want me to give?’

of acceptance in reaction to a proposal.

‘Good idea.’

Implicit coordination of actions

Providing unsolicited

task-relevant actions Include task-relevant actions completed without being asked

to do so.

After the physician announces he/she is going

to intubate, the nurse holds out the laryngoscope.

Table 13.1 Continued

Category Definition example

offers help ‘Can I help you with this?’

Indications of

satisfaction with

fulfilment of task

Include statements of general agreements ‘Fine.’‘Okay.’

‘Good.’

Monitoring (patient or

of the patient.

Reading indicators on a monitor.

expressing personal need for something (without asking another person for it).

‘I don’t have gloves.’

‘I’m so thirsty.’

Heedful interrelating

Watching actions of other

colleagues

Team member watches what another team member

is doing

Verbalizing own

communicated.

‘I’m calling the attending.’

‘I’m turning the alarm down.’

Verbalizing interpretation

better.’

Correcting behaviour of

another’s condition influencing task fulfilment.

‘Are you okay?’

‘Thanks.’

or demonstrations beyond the mere correcting of a behaviour

of another team member.

‘The way you did that wasn’t wrong but it’s easier

if you do it this way.’

Giving feedback in a

Giving feedback in a

consequences of personal or other’s actions.

‘We have to be careful with this tube because we have to put him in a prone position afterwards.’

Table 13.1 Continued