A team mental model approach to understanding team effectiveness in an emergency department: A qualitative study

Abstract

Objectives

To demonstrate how the team mental model concept can broaden our understanding of team effectiveness in health care by exploring the knowledge that underpins it, and the workplace conditions that sustain it in a metropolitan emergency department (ED) in Sydney, Australia.

Methods

This study draws on accounts of 19 ED clinicians (registered nurses, doctors and nurse practitioners) of their teamwork practice and perceptions of their team’s effectiveness through semi-structured interviews. Analysis was conducted in two stages. A thematic analysis was followed by a template analysis using the a priori themes of task, team, team process and goal knowledge to specify the content of the team’s mental model.

Results

The content of the ED team’s mental model revealed that the knowledge the team employed to coordinate their work was deeply embedded in the team’s tasks and the workplace context. Team effectiveness not only relied on how well team members coordinate, but also their ability to perform their own role effectively and efficiently. Three workplace conditions were identified as enablers to individuals acquiring the knowledge needed to work effectively in the team: stability in team membership; workplace experience; and the spatial-temporal conditions of emergency work where permanent emergency doctors and nurses executed their tasks concurrently, regularly interacted and shared a common goal.

Conclusions

Getting health care teams ‘on the same page’ is a long-standing challenge. This study suggests that solutions may lay in the organisation of health care work, creating team stability and opportunities for team members to interact that allows a team mental model to emerge.

Keywords

flexibility shared mental model teamwork

Introduction

Most work processes in health care are large and complex, comprising interdependent tasks that require the collective effort of a team. Yet, the reality of teamwork in health care is fraught with problems, often blamed on siloed and antagonistic relations between the health professions.^1,2 Research and interventions in health care teams have focussed on identifying and resolving common dysfunctional teamwork behaviours such as poor communication, inter-professional conflict, and the absence of shared goals.³ Much less attention has been given to what makes for effective health care teams.

Team effectiveness involves balancing the stable, predictable performance needed for efficiency and reliability, and the flexibility needed for responsiveness and adaptability.^4,5 In health care, this balance entails teams minimising unacceptable variations in patient outcomes by following established models of care and clinical guidelines, while allowing professionals to exercise clinical judgement to respond to individual patients’ needs⁶ and to adapt to dynamic workload conditions. The ‘team mental model’ (TMM) concept helps explain how teams achieve this balance. A TMM (sometimes called a ‘shared mental model’) is a mental representation of the team’s work shared by team members that emerges as they interact in the workplace.^7,8 Team members with a similar and accurate mental model share an understanding of events in the workplace, why they occur, how to respond appropriately, and can anticipate what is likely to happen next.⁹ This state is thought to be the cognitive basis for the smooth, effortless coordination observed in effective teams, even when faced with complex and unpredictable work.¹⁰ Such teams are often described as being ‘on the same page’.^8,9

A TMM encapsulates all aspects of knowledge needed to work in a particular team.⁸ Wildman et al.’s⁷ review of the team knowledge literature identified four key components: task, team, team process and goal knowledge. Task knowledge is the knowledge and skills that each team member needs to perform their own duties. Team knowledge allows team members to coordinate effectively through an understanding of role responsibilities within the team, where those responsibilities are interdependent and overlap, and to locate relevant expertise within the team. Team process knowledge refers to an understanding of the expected processes, procedures and behaviours needed to coordinate with others. Finally, goal knowledge captures a team’s mental representation of their shared goals and objectives. Team knowledge also has a temporal dimension, with some aspects being relatively static over time (providing stability and predictability) while others are dynamic, changing according to immediate workplace conditions (providing flexibility).⁷ The knowledge that comprises a TMM is therefore highly variable and context-dependent.^7,8

To date, there has been limited research on the role of TMMs in health care teams.^8,11,12 To our knowledge, there are no studies that have described the knowledge that underpins a TMM, or the conditions that sustain it. This paper addresses this gap by detailing the TMM of an Australian emergency department (ED) team, where efficient and reliable performance had to be accomplished under highly unpredictable and volatile conditions.

Method

This paper draws on ED clinicians’ own accounts of their teamwork practice and their perceptions of what helped or hindered effective team performance. The study was part of a wider explanatory sequential mixed methods study that explored team flexibly in response to dynamic workload demands¹³ conducted between March 2015 and February 2016. In the first phase, a time study measured the tasks of registered nurses (RN), nurse practitioners (NP) and doctors (DR) as they performed their everyday clinical work. The findings from this work informed the design of clinician interviews, which we present in this paper.

Study site

The study site was the ED of a metropolitan tertiary referral hospital in Sydney, Australia with an annual presentation of approximately 75,000 patients.¹⁴ The ED was typical of others in terms of the range of patients treated, models of care, and clinical roles.¹⁵ There were 146 full-time equivalent (FTE) RNs (including four NPs). In Australia, NPs have a protected title, requiring a Master’s degree and having a legal mandate to autonomously diagnose, prescribe for and refer patients within their scope of practice. The ED was also staffed with 64.5 FTE doctors of whom 28.5 FTE (44%) were junior doctors on rotation through the hospital. The study was set in the ‘Fast Track’ area of the ED, a model of care that had been in place for approximately three years at the time of our research, designed to quickly treat and discharge patients with minor injuries and less complex medical conditions, mainly those triaged as non-urgent or semi-urgent. The ED’s performance in discharging such patients within four hours was slightly above the Australia average, at 91% compared to 89% for non-urgent and 76% and 75% for semi-urgent patients.¹⁴

Responsibility for patient care in Fast Track was divided between two roles: RNs and ‘treating clinicians’, either a doctor or NP. Registered nurses assessed waiting patients first and had extended role responsibilities to order investigations (e.g. X-ray, pathology), medications and other supportive treatments to manage patients’ symptoms. They also performed procedures and treatments delegated from doctors and NPs, monitored waiting patients, and undertook the hospital admissions process. After the initial RN assessment, a doctor or NP undertook a clinical examination, ordered any further investigations, reviewed results, consulted colleagues, prescribed medications, performed any clinical procedures required, then admitted or discharged the patient.

Data collection

Semi-structured interviews explored the underlying knowledge and cognitive processes behind the teamwork behaviours observed in the workplace, as well as clinicians’ perceptions of the barriers and facilitators to their team’s effectiveness. Topics covered were drawn from the findings of the work observation phase of the study¹³ and included: the process of task delegation within the team; the challenges the team faced in coordinating their work; attitudes to RNs’ autonomy to order medications and investigations; and perceptions of the NP role.

Interview participants were purposively selected from volunteers who responded to an email or study information poster displayed in staff areas. Volunteers were stratified by role to capture the range of clinical experiences. Sample adequacy was achieved through data saturation, signalled by replication of insights provided.¹⁶ Interviews took place in a private office in the ED to allow participants to speak freely and be at ease in their surroundings. They were conducted by one researcher (SW) at times which minimised the impact on ED operations. Interviews lasted between 20 and 50 minutes, with an average of 35 minutes. Before commencing the interview, the researcher explained the study, answered any of the participants’ questions and obtained signed consent. Interviews were audio-recorded and transcribed verbatim.

Analysis

Interview transcripts were analysed using NVivo v11. The interview data were first analysed thematically (SW). Open codes were created by noting frequently recurring and evocative phrases, ideas and perceptions, then grouped into meaningful themes in an iterative process.¹⁷ Thematic analysis found that the TMM concept could elucidate the type of knowledge the team used. A second, template analysis¹⁸ was conducted to specify the content of the team’s mental model (SW). After both stages of the analysis (thematic and template), a random selection of six to eight transcripts was recoded by a second researcher (MF) to test for consistency in the interpretation of the coding framework.¹⁹ One researcher’s prolonged exposure to the Fast Track environment during the work observations (SW), and another’s ED clinical experience (MF) strengthened the interpretation and provided contextual understanding of the findings presented here.

The a priori themes for the template analysis were based on Wildman et al.’s⁷ four components of team knowledge: task, team, team process and goal knowledge. The analysis also captured the temporal dimension of each type of knowledge (with the exception of goal knowledge which, in common with Wildman and colleagues’ view, did not have a clear temporal dimension). Knowledge was coded as ‘static’ if it was relatively unchanged over time, and ‘dynamic’ if it was the type of knowledge needed to respond to emergent workplace demands. For example, the method of performing a procedure was coded as ‘static’ since it does not change substantially over time or between patients. In contrast, the judgement used to decide whether to perform the procedure, or delegate to someone else was coded as ‘dynamic’ if it was contingent on contemporaneous workload conditions.

Ethical approval

Ethical approval was granted by the hospital’s Human Research Ethics Committee (South Eastern Sydney Local Health District HREC Reference 14/144).

Results

A total of 19 clinicians (registered nurses, nurse practitioners, doctors) participated in interviews (Table 1).

Table 1.

Interview participant information.

	n (%)	Mean number of years registered (SD)
Gender
Female	13 (68%)
Male	6 (32%)
Role
Registered nurse	8 (42%)	18.5 (3.1)
Doctor	7 (37%)	14.0 (9.7)
Nurse practitioner	4 (21%)	13.0 (11.2)

Overall, the experienced clinicians interviewed were remarkably consistent in their descriptions of the underlying knowledge and cognitive processes behind their teamwork behaviours, indicating that they shared a similar mental model. The task, team, team process and goal-related knowledge that comprised that mental model are described in turn, and summarised in Figure 1. The workplace conditions that were identified as barriers to or facilitators for individual team members acquiring this knowledge are discussed alongside these findings, with illustrative quotes provided throughout the text.

Figure 1.

Summary of the knowledge content of the ED team's mental model.

Task knowledge

Task knowledge is the knowledge and skills required for each team member to perform their duties. Doctors’ and NPs’ task knowledge focussed on the diagnosis and treatment of the wide range of patient conditions presenting to Fast Track. Registered nurses’ task knowledge included that required to fulfil their extended role responsibilities, such as ordering investigations and prescribing medications for symptomatic relief. All three roles needed technical skills in high frequency procedures, such as venepuncture, and systems knowledge such as the electronic medical record system used in the ED, referral pathways and admissions processes. This task knowledge was relatively static over time but some of it was specific to the ED and therefore acquired on-the-job. As RN5 below explains, RNs undertook training for their extended role responsibilities and were guided by protocols but the ability to execute those duties quickly and independently developed with workplace experience.

Nurses with less experience don’t really know what the process is… “Should I cannulate this person or should I take bloods from them?” Because you don’t know, you just wait to be asked. Whereas, with experience you know “this kind of patient generally gets this done”, you just go and do it. RN5

The dynamic aspect of task knowledge entailed the clinical judgement needed to apply this knowledge flexibly. Interview participants emphasised that the deep task knowledge held by experienced clinicians allowed them to make rapid decisions in response to a patient’s condition and set priorities according to prevailing workload conditions. In contrast novice clinicians were more reliant on protocols and less effective in task prioritisation.

[NPs] target minor injuries and illness and have more than ten years’ experience so we can manage those things really quickly, we have the confidence and skills in what we need to do, and what we can ignore… compared to [junior doctors], who take four hours to manage one patient because they need to consult and work through the guidelines. NP1

Dynamic and context-specific task knowledge develops through workplace experience. Therefore, the presence of novice clinicians inevitably impacted the team’s effectiveness, especially in an environment where timeliness and efficiency are essential. The ED is a mandatory rotation in post-registration medical training, and new junior doctors rotated through the department every three months. They required significant support from senior clinicians to ensure they delivered an acceptable standard of care, but never acquire the depth of task knowledge needed to work effectively and independently. Senior doctors rarely worked in Fast Track and therefore NPs were recognised by their colleagues as playing a key role in developing junior doctors’ task knowledge. The stable presence of NPs allowed the team to maintain a safe and consistent standard of care for Fast Track patients, as one NP explained:

NPs take the peaks and troughs out of performance from both medical and nursing staff by being the stable workforce that actually can say ‘This is how we expect conditions to be managed. NP2

Team knowledge

The team knowledge prominent in the interview data comprised an understanding of each role’s responsibilities, as well as individual team members’ specific skills. Such knowledge allowed team members to locate relevant expertise within the team, for example who to consult for advice or to appropriately delegate a task. While this task knowledge was relatively static, RNs’ extended responsibilities and NPs’ role as autonomous clinicians were unusual in the Australian hospital context. Moreover, role responsibilities in the Fast Track model of care were slightly different from the rest of the ED. Study participants reported that junior doctors and others new to the department who lacked this specific team knowledge occasionally caused conflict over role responsibilities, and errors or delays in patient care. In contrast, ED clinicians who had worked together for some time had a deep understanding of each other’s roles, task interdependencies and strong interpersonal relationships, which facilitated smooth, effortless coordination as this senior emergency explains:

… the more senior the person would work better in terms of integration and trying to help each other rather than working independently…. or duplicating the work. So, that would be one aspect; the experience of knowing or anticipating what the other person can do. DR3

Dynamic team knowledge involved an understanding of how prevailing workload conditions affected each role, and how to best utilise team members’ skills to manage workload across the team. At the team level, the senior doctor and RN managing the flow of patients through the ED had to ensure that patients were appropriately matched to individual team members’ skills. At the individual level, doctors and NPs consistently reported that they considered relative workloads between them and the RNs before delegating a task they could perform themselves, such as venepuncture. As the following quote illustrates, their concern was to avoid delays in the task being completed, and to prevent RNs from becoming overloaded:

If I’ve seen a patient and I think they need bloods I’ll see if I can find one of the nurses to do it, but it depends on their workloads if they’re really busy and you think, “Well, it’s probably not gonna get done because they’ve got all this other stuff to get done” so there’s gonna be another delay … in which case, I go back and do it myself. DR7

Likewise, RNs stated that they were happy to perform such shared tasks when doctors and NPs were overloaded. This dynamic team knowledge that took account of relative workloads demonstrates that team members understood their roles were interdependent and that responsibility for the team completing its tasks was shared.

An understanding of each other’s roles, task interdependencies and strong interpersonal relationships appeared to emerge between stable members of the team. The large number of staff that worked in the ED, and the continuous rotation of junior doctors made it difficult to sustain this level of team knowledge. As DR7 pointed out, it was “…hard to learn everyone’s names” let alone their individual skills, or develop a working relationship with them. Moreover doctors, RNs and NPs worked different shift patterns, causing the composition of the team to change multiple times per day. This team instability was particularly problematic for doctors and NPs trying to locate the right nurse to delegate tasks to since “…when it’s busy and you’ve got breaks and you’ve got [nurses] coming in and leaving and the medical staff up in arms, going, ‘I don’t know who to tell’” (NP4). However, there were spatial-temporal conditions in ED work which fostered team knowledge development. Unlike hospital wards where “doctors are not really around much” (RN2), ED doctors and nurses were co-located and executed their tasks concurrently allowing both the static and dynamic aspects of team knowledge to emerge between stable, permanent team members.

Team process knowledge

The team process knowledge most often discussed by study participants concerned the frequency and mode of explicit communication required to ensure each team member had the information they need to do their job. A shared understanding of how to provide the right information, when to provide it and to whom, was essential for avoiding errors and delays in patient care. Registered nurses commented that they could only complete the discharge and admission process when doctors or NPs updated a patient’s electronic medical record in a timely manner. Participants from all three roles also emphasised that doctors and NPs had to verbally delegate a task such as medication administration to RNs, in addition to documenting it in the patient’s chart. Several workplace factors drove the need for frequent communication in Fast Track including: the quick turnover of patients; patients spread across multiple areas (consultation rooms, waiting rooms and beds); and the high number of patients per staff compared to other areas of the ED. In this environment explicit communication between RNs was also essential to avoid errors and omissions since tasks were often delegated from one RN to another, especially between shifts:

I mean when it comes medication administration, generally it doesn’t go wrong except when a message doesn’t get sent across, that’s always a lack of communication. Someone hasn’t passed the message on to the next person. Because you’ve got documentation, you know it hasn’t been done or hasn’t been given, but there has been a delay. NP3

The dynamic team process knowledge evident in the interview data was that communication between doctors and nurses was a two-way negotiation. For example, a crucial element in delegating tasks according to relative workloads described under ‘dynamic team knowledge’ was that nurses could (and should) decline to perform the task if they were too busy to complete it quickly. As the quote below highlights, senior doctors also relied on RNs to challenge doctors’ decision-making to protect patient safety:

[Emergency nursing staff] … are more willing to challenge any level of hierarchy if they think it’s in the patient’s best interest … having that back up means if they don’t think things are going correctly that they are allowed to go, “Hang on. We need to re-evaluate that.” …or… “This needs to have someone else review it.” Having that sort of support from nursing staff is something that is different from a lot of other environments within the hospital. DR1

Study participants from all three roles commented that this egalitarian approach to doctor-nurse communication was unique to the ED, driven by the urgency and volume of emergency work, and the disparity in workplace experience between registered nurses and the numerous junior doctors in the team.

Goal knowledge

Evident across the task, team and team process aspects of the team’s mental model was a shared understanding that their goal was to provide timely quality care to keep patients flowing safely through the ED. That the RN quoted below jokes about the goal being to meet the government’s target of treating and discharging patients within four hours is indicative of broader attitudes within the team:

I find that there are few exceptions to the rule but generally, particularly in Fast Track, there’s an attitude of helping each other and I think it’s an understanding that we’re doing similar roles. We’re trying to achieve the same kind of goal, which is to get them out in four hours <laughs>…. RN6

While the ‘four-hour’ performance rule and other time-based targets were a reality of ED work, they were not a dominant factor in unifying the team. Rather, the imperative for doctors and nurses to work interdependently towards a common goal arose from the urgency and unpredictability of ED work, and the spatial-temporal conditions of the workplace. As for team knowledge, doctors and nurses shared a workspace and executed their tasks concurrently therefore the whole team shared the consequences of errors and delays that caused poor workflow and an overcrowded ED, and prevented them from achieving their goal.

Discussion

Analysing the content of an ED team’s mental model in one metropolitan tertiary referral hospital in Australia revealed that the range of knowledge teams employ to coordinate their work appears to be much broader than that typically considered in the teamwork literature. We further show that this knowledge is deeply embedded in the workplace context. Moreover, team effectiveness not only relies on how well team members coordinate with each other, but also on their ability to perform their own tasks effectively. Across all four areas of team knowledge, three interrelated workplace conditions appeared to enable a shared TMM: stable team membership, workplace experience, and the spatial-temporal conditions of work.

There is a growing body of evidence across health care settings of a positive relationship between stable team membership and effective team performance.^20–22 A similar and accurate TMM emerges when a stable group of team members regularly interact,^8,9 yet the organisation of health care work produces highly unstable teams.^23,24 Hospital wards and units, including EDs, are staffed around the clock by nursing and medical staff on different shift patterns, therefore team composition changes several times per day. Confirming the findings of other work,^23,24 the ED team in our study perceived that communication errors and delays were most likely to occur during the multiple handovers between shifts.^22,24 In the longer term, ever-changing team membership hinders the development of the knowledge of each other’s roles, skills, and the interpersonal relationships that otherwise enhance coordination.^10,22 Even in the favourable ED environment where a core of permanent doctors and nurses did share this team knowledge, the presence of a transient junior doctor workforce limited the extent to which the TMM would be shared across all team members.

Problems stemming from a lack of team and team process knowledge, including errors, delays and task duplication, were perceived to occur more often when team members had less workplace experience. Workplace experience is also crucial for developing the task knowledge individuals need to perform their own duties effectively and efficiently. Health professionals learn to apply the theoretical knowledge acquired in formal education by treating real patients under the guidance and supervision of more experienced colleagues,²⁵ in the present study often undertaken by nurse practitioners. This form of teamwork helps others complete their tasks in a timely manner, safeguards quality and safety, and increases individuals’ (and therefore the team’s) effectiveness over time.²⁶ Despite the importance of this process for professional development, the capacity of health care teams to absorb novice clinicians while maintaining reliable performance is not well understood.²⁵

Workplace experience is particularly important for developing the dynamic knowledge teams need to work flexibly, that is, responding to complex patient needs and adapting to workload demands.^9,10 As Farjoun⁴ argued, safety-critical work often demands low-variance, consistent outcomes to be accomplished under unpredictable conditions. This requires team members to be flexible to prevailing conditions (e.g. using the dynamic knowledge of clinical judgement), supported by underlying stable mechanisms (e.g. the static knowledge of clinical guidelines). The static and dynamic knowledge of the TMM shared by permanent, experienced ED clinicians both stabilised team’s performance, and enabled the responsiveness and adaptability needed to deliver safe patient care under highly volatile conditions.

Finally, the spatial-temporal conditions of ED work were a significant counterbalance to the problems of team instability and workplace inexperience described above. The co-location of permanent ED doctors and nurses may explain why the shared goals of timely and quality patient care, a sense of shared responsibility for the team’s tasks, and egalitarian doctor-nurse communication were such strong features of the team’s mental model. These features are usually found lacking in health care teams in other settings,^1,2 but have been identified in studies of ED teams.²⁷ By working concurrently under time pressure, ED doctors and nurses gained a deeper understanding of each other’s roles, and of how to work interdependently. Their work was highly visible to each other and they shared the consequences of high workloads and problems in patient flow. These spatial-temporal conditions are unusual.²⁴ In other hospital settings, doctors are not always present to see the pressures of nurses’ work, and vice versa, causing misunderstandings around role responsibilities and priorities to arise.²⁸ Moreover, the physical environment, such as work stations and social areas are not designed to maximise the regular interactions between the professions to allow a shared TMM to emerge.^23,29

The team mental model concept explored in this study helps broaden our understanding of what underpins team effectiveness in health care. Current research is predominantly concerned with individual attitudes and teamwork behaviours, especially communication.³ Empirically, teamwork behaviour is treated as a separate phenomenon from the team’s tasks, and the dynamic workplace context where it takes place. Likewise, interventions to modify attitudes and behaviours are typically conducted away from the workplace, in classrooms (e.g. interprofessional education) or simulation facilities (e. g. team training), and/or overlays democratic structures (e.g. multi-disciplinary meetings) or communication protocols onto existing workplace conditions. There is growing recognition that this narrow, decontextualised approach has contributed to the failure of teamwork interventions to achieve sustained improvements in team effectiveness over time.^24,30 For practice, if health care organisations are serious about the centrality of teams and teamwork for safe and effective patient care, then traditional staffing practices require a radical rethink. A shift is needed from monoprofessional rostering to an interprofessional, team-based approach that maximises stability in team membership over the long term, aligns shift patterns to minimise team instability in the short term, and designs the physical care environment to increase the opportunities for interprofessional team members to interact.²⁹ Rotating junior doctors, who face significant challenges integrating into teams with a limited understanding of each new workplace’s TMM, would particularly benefit from these measures.

Limitations

The study’s confinement to the Fast Track area of one metropolitan ED means the content of the TMM and workplace conditions identified may not be transferable to other environments. However, looking in-depth at one TMM elucidated the importance of tasks and context in driving team effectiveness. Future research could use the method described here to identify the content of, and barriers to and enablers for teams acquiring and developing a TMM in health care contexts without the ED’s spatial-temporal advantages such as hospital wards and geographically dispersed teams.

Conclusion

The static and dynamic knowledge shared between experienced team members allows teams to effectively manage the duality of stability and flexibility and so deliver safe and effective patient care under highly volatile conditions. Getting health care teams ‘on the same page’ in this way is a long-standing challenge. This study suggests that solutions may lay in the organisation of health care work, creating the team stability and opportunities for team members to interact that allows a team mental model to emerge.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics approval

Ethics approval was granted by the hospital’s Human Research Ethics Committee (HREC) (South Eastern Sydney Local Health District HREC Reference /144) and was ratified by the University of Technology Sydney HREC (Reference 2014000719).

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research was supported by an Australian Government Research Training Program Scholarship, and the University Technology Sydney Chancellor’s Research Scholarship.

ORCID iD

Sarah Wise

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