Frame the work

Leaders have an opportunity to frame the work at the start of a shift, procedure, or case or even mid-way through working with others to reset the course. One important aspect of this framing is the development of a mutual understanding of the work. The value of developing a shared understanding of the situation has been demonstrated in a range of contexts including healthcare. For example, interprofessional teams in acute care that developed mutual understanding were better able to innovate in their work.18 In contrast, without this kind of shared sensemaking, teams will be more likely to fail to adapt in a crisis; this failure can be devastating, as it was, for example, when the lack of shared sensemaking contributed to the failure to adapt and the loss of lives in the Mann Gulch fire.19 In short, leaders who help others to make sense of the unfolding situation can foster adaptation. Moreover, developing a mutual understanding can provide the stability19 that is much needed in the face of exhaustion and a complex problem.

Leaders also have an opportunity to frame the task in terms of who is (or should be) involved. In highly complex organisations, such as hospitals, leaders would be well served to frame the task as involving a broad network of individuals, thereby shifting attention from oneself or one’s unit to the larger system of healthcare providers—bringing into relief what kind of coordination is possible and increasing the likelihood of coordination across boundaries.3 For example, when inpatient physicians viewed other professions as a part of the overall work of providing care, they were more likely to effectively involve those other professions into the work—communicating with them and involving them in decision-making—which, in turn, enhanced both how much the physicians learnt and overall efficiency of care.7

Finally, leaders can make use of roles: the set of expectations that come with a defined position.20 Roles can serve as a guide to help strangers coordinate, but those roles often have grey areas. This was documented in the early 1990s with flight crews, in which roles were previously thought to be quite clear and rigid,21 and it holds in healthcare. From hospital to hospital, unit to unit, even attending to attending, expectations of a role can vary. An intern working with one attending physician might face different expectations from week to week as attendings change.7 Even within a shift, an attending physician might delegate and then reassume authority over a certain task.22

This fuzziness creates a need to discuss roles and lay the foundation for role flexibility. If an individual can see and understand the general expectations that come with her own role and how that fits with others’ roles, she will better see how to coordinate her expertise with others as well as how to adapt in the face of an evolving situation. Critically, management research from a wide range of industries including healthcare suggest that role clarity as well as role flexibility and the backup behaviour described above can be jumpstarted at a team’s onset. For example, in inpatient teams, when the team’s weekly start was used to highlight roles and interdependencies, subsequent teamwork, learning and care performance improved.7

Taken together, this research suggests that leaders can use the start of a shift, procedure and week, to frame the work and establish a mutual understanding, create a team orientation and clarify roles. These practices are likely to be particularly important during the COVID-19 outbreak, given the dual conditions of ambiguity and a fluctuating workforce.

Leverage communication structures

Practising closed-loop communication and relying on current structures such as handoff routines should benefit care performance, as mentioned above. Leaders can use these structures to both adapt in the moment and learn. Adaptation is essential when responding to a crisis19 as old ways of working can be rendered inadequate as the environment shifts.23 Critically, routines are (and should be) adaptable in that they can evolve over time, and elements of different routines can be combined to create a new approach to the work at hand. For example, research with US Marine Corps and cyber-security teams demonstrated that when elements of past routines were recombined on the fly to develop new approaches to the work, teams were able to effectively adapt to the changing environment.24 To this end, healthcare professionals can take steps both before and during responses to the evolving COVID-19 outbreak. Ahead of a local surge in patient numbers, healthcare professionals can establish and reinforce their communication norms and routines; for example, leaders can ensure the widespread use of closed-loop communication or best practices for handoffs. Then, amidst responding to the crisis, they can return to those communication structures as resources, using elements of them as fodder for creating emergent ways of organising. For example, handoff guides might be adapted to establish a new procedure for handoffs from a newly created triage area.

That said, the continued or even increased use of extant routines focused on reflection can ensure learning and improved performance over time. For example, ‘after action reviews’ are used in the military to ensure opportunities to learn from past experiences.4 Similar in concept, guided debriefs (relative to no reflection or unstructured reflection) enhance subsequent teamwork and performance25 and have been widely called for and implemented in surgical settings.16 Debriefs can be used at the end of shifts, too. Though debriefs take time, leaders’ inquiry—asking for reflection about what happened and why, as well as how to implement any lessons learnt—can ensure that issues are rising to the surface. In times when achieving resilience at the frontline may have the unintended consequence of masking real organisational issues, leaders must work to surface any signs of vulnerability so that they can address them.19

Practice inclusivity

Management research suggests that teams with a high collective intelligence are likely to surface and use relevant knowledge.26 To this end, leader inclusiveness has been shown to overcome multiple challenges to surfacing information in a range of contexts. The first challenge is a statistical one. Groups tend to focus on commonly held information and fail to recognise uniquely held pieces of information—information held by one or few members—that is important to the work at hand.27 Even when that unique information is voiced, it is often not trusted because others might not be able to corroborate it.27 Yet, the presence of uniquely held information is exactly the point of using multidisciplinary teams, in which team members can bring different knowledge and perspectives to the table. Leaders can help their teams to overcome this tendency to focus on commonly held information by engaging in inclusive behaviour. For example, in teams of physicians making medical diagnoses, leaders were found to play an ‘information management role’ in that they asked fellow teammates more questions about case information and repeated the unique information voiced by teammates;28 such pooling of unique information has been shown to improve outcomes such as diagnosis accuracy.29

There is a second challenge to ensuring that all relevant information is surfaced in that there are also social forces at play. Hierarchy is deeply embedded in healthcare culture, and while hierarchy enables coordination,30 it also creates a risk that individuals lower in status will remain quiet and withhold important information for fear of speaking out of line.31 Here, too, inclusive behaviour from leaders can ensure that members feel a sense of psychological safety and are willing to participate.32

A word of caution

Teamwork, quite simply, is critical to providing care quality and safety. However, teamwork can have a dark side, too. As the focus on teamwork grows, there is a risk of losing sight of individual well-being. A study in nursing homes found that within a strong teamwork climate, employees were more likely to continue to work while sick rather than stay home,33 behaviour that poses a great risk when fighting a pandemic. As clinical and managerial leaders work to ensure that any given person in a healthcare system adopts a team orientation, their leadership is also needed to ensure that individual well-being is maintained.