A Night With Red Eyes Reveals How Teamwork Unfolds in Out-Of-Hours Primary Care

Introduction

During the night between October 21 and 22, 2024, the Out-of-Hours Primary Care (OOH-PC) night service detected several patients reporting burning eyes – without any obvious explanation for the symptoms. After a few calls, the team identified a pattern. The patients were all students at Aarhus University and had been at the same location at the university the previous day. The staff now faced a task they had not encountered before, and for which no protocol existed. The team had to adapt to this new situation and change its work structure accordingly.

Teamwork plays a significant role in the management and unfolding of critical incidents. ¹ Teamwork in telemedicine has previously been studied, but these studies have typically focused on factors such as the physical distance between employees. ² The type of collaboration described in these studies thus differs markedly from the triage team setup in the OOH-PC night service in the Central Denmark Region, where team members are co-located and structured as a team following the reorganization of this service, which took effect on 1 March 2024.

The OOH-PC night service team in the Central Denmark Region is characterized by relatively stable patterns of teamwork behavior. This is shown by predictable demands, co-location, overlapping competencies, and simultaneous task execution. ³ These qualities are well suited to solve the usual tasks in OOH-PC. However, multiple simultaneous calls from university students made the team aware of a potentially critical situation, although this only became apparent gradually. Although patients’ symptoms were not considered severe, uncertainty about their cause, combined with the evacuation of Aarhus University, led to extensive media coverage. ⁴ The incident was considered critical both because the OOH-PC night service team faced an unfamiliar situation outside their usual scope and because of the way it was managed in the absence of protocols, prompting internal reflection and public attention.

This case study aimed to explore how teamwork behaviors within an OOH-PC triage team influenced the management of an unforeseen critical incident, particularly how both prior and situation-specific teamwork behaviors were crucial for cooperation during the incident. Rather than evaluating the effectiveness of the team’s response, the study focuses on how the team navigated the situation.

Methods

This organizational case study (see Supplemental File 1 for adherence to appropriate reporting guideline) is based on a focus group interview following a semi-structured interview protocol with two (of five) employees (one nurse, one physician) in the OOH-PC night service in the Central Denmark Region who were on duty during the critical incident between October 21 and 22, 2024. The interview lasted 1 hour and took place on 18^th December 2024. During the incident, twenty-three students developed symptoms of burning eyes after accidental UV exposure from a malfunctioning university disinfection system, initially suspected as chemical or biological contamination, prompting campus evacuation and a multi-agency response. The interview was audio recorded and subsequently transcribed verbatim, anonymized, and the audio recordings were deleted. The interview guide is available in Supplemental File 2. The first author conducted a theory-driven thematic analysis using deductive coding focused on teamwork. ⁵ After several readings of the interview, the coding process began. The codes were grouped into three themes.

Results

Three themes were apparent in the employees’ experience of the critical incident and their interpretation of teamwork during the shift. Each theme is unfolded below, and teamwork literature is applied to elaborate the analysis.

Discussion

The following discussion examines teamwork during the critical incident, with a focus on both the dynamic and established professional roles. A model of team adaptation is used to illuminate how preexisting team characteristics may have influenced the team’s response.

As the incident unfolds, decision-making is handed over to the physicians following the procedure of delegation in situations that fall outside the nurses’ typical area of responsibility. When assessing the shared symptoms across patients and determining how to manage the situation, physicians assume clinical responsibility in line with their role. The incident therefore does not so much alter the team’s work structure as make the existing hierarchical role structure more pronounced. Physicians take primary responsibility for assessment and decision-making, while nurses continue to manage ongoing calls and other operational tasks. This contrasts with employees’ description of the OOH-PC night service as usually operating with a relatively flat structure.

Collaboration in the OOH-PC night service is characterized by predictable demands, co-location, overlapping competencies, and simultaneous task execution. ³ These characteristics are well suited for handling the usual tasks. The handling of this incident can be viewed as a ‘project’, which shifts the team’s structure from being ‘service-oriented’ to ‘project-oriented’. ⁹ The shift in task changes the team’s characteristics, where there are no longer predictable demands or overlapping competencies. The hierarchical structure becomes more pronounced, and the employees become more dependent on each other, as the task places greater demands on coordination. ³ Leadership in a challenging situation has been found to create insight into and correct issues. ⁷ Hence, the division of labor during the critical incident is not necessarily problematic but can be seen as a sign of a dynamic team capable of adapting to new tasks.

Hierarchical division of work promotes role clarity but is, in theory, limiting the conditions that support teamwork. ⁸ In the OOH-PC night service, the experience of team competence or collective efficacy ⁷ may be maintained through close communication, existing mutual professional respect, and knowledge of other employees’ competencies. Burke et al ¹⁰ model for team adaptation highlights how these characteristics can be prerequisites for adaptation (Figure 1).OPEN IN VIEWER

The team’s characteristics are positively related to the first phase of team adaptation in the model: situation assessment. ¹⁰ This phase begins when an employee picks up on a cue. The model explains a progression from situation assessment to plan formulation to plan execution. However, the essential aspect of the model is the emergent states that arise within each phase and are crucial for the next stage. During situation assessment, meaning is ascribed to the event, which creates shared mental models and team situational awareness among the involved employees.

Of relevance to the critical incident analyzed in this study is the delegation of plan formulation to the physicians. Involving staff provides the best foundation for adaptation, as it maintains a shared understanding of the situation throughout. ¹⁰ The successful handling of the situation can be explained by the existing communication patterns in the team, where employees – despite the division of labor – still gain insight into decisions and could be heard. The prioritization during the incident may be attributed to the workload from the concurrent “normal” calls, which the team still had to handle.

The seemingly contradictory perception of a flat work structure coexisting with a traditional division of labor between professions must be understood in the context of the team’s workload in terms of managing incoming calls and responding to an unfamiliar situation. From a theoretical standpoint, it might have been more optimal to involve all staff members in the planning phase. The team nonetheless maintained situational awareness and shared understanding. This was achieved through communication patterns facilitated by co-location, mutual professional respect, and a shared team identity. These teamwork characteristics appear to emerge organically from the employees themselves, shaped by team composition, task demands, physical context, and the nature of their roles. ¹⁰ This study highlights that these characteristics form the foundation for a dynamic handling of an unfamiliar event. Supporting these characteristics will improve the ability of similar teams to respond to situations for which no protocols exist.

Some limitations of the present study should be noted. First, the study is based on a focus group interview with two employees who were on duty during the incident. Although the participants had direct experience with the event, the limited number of participants may restrict the breadth of experiences represented. Still, the interviewed employees represent 40% of the employees on duty during the event. Second, direct observations of teamwork during the incident might have yielded different results. Hence, the present study might reflect how participants interpreted the event afterwards rather than an objective account of the incident. However, direct observation during an unforeseen critical event might be difficult to capture. Despite these limitations, qualitative methods were appropriate for the aim of the study. The case study design and semi-structured interview enabled in-depth examination of contextual factors, communication patterns, and professional dynamics that would be difficult to capture using quantitative approaches. However, the findings should be understood as context-specific and exploratory rather than generalizable, but they may serve to generate insights and hypotheses for future research on teamwork in OOH-PC triage settings.

Conclusion

This case study highlights how teamwork behaviors within an OOH-PC triage team influenced the management of an unforeseen critical incident. Rather than assessing performance, the analysis shows how both enabling and constraining aspects of teamwork shaped the team’s response. The findings suggest that features such as informal communication structures, co-location, and mutual professional respect may support adaptive capacity in OOH-PC settings characterized by high task interdependence, time pressure, and the need for real-time coordination in the absence of established protocols. The study contributes to the literature by describing team collaboration in an OOH-PC triage team and its implications for handling the event. By identifying essential aspects of teamwork, other teams can prepare not only for similar situations but also for unforeseen incidents.

Supplemental Material

Supplemental Material