Abstract
Purpose – Complex clinical situations, involving multiple medical specialists, create potential for tension or lack of clarity over leadership roles and may result in miscommunication, errors and poor patient outcomes. Even though copresence has been shown to overcome some differences among team members, the coordination literature provides little guidance on the relationship between coordination and leadership in highly specialized health settings. The purpose of this paper is to determine how different specialties involved in critical medical situations perceive the role of a leader and its contribution to effective crisis management, to better define leadership and improve interdisciplinary leadership and education. Design/methodology/approach – A qualitative study was conducted featuring purposively sampled, semi-structured interviews with 27 physicians, from three different specialties involved in crisis resource management in pediatric centers across Canada: Pediatric Emergency Medicine, Otolaryngology and Anesthesia. A total of three researchers independently organized participant responses into categories. The categories were further refined into conceptual themes through iterative negotiation among the researchers. Findings – Relatively “structured” (predictable) cases were amenable to concrete distributed leadership – the performance by micro-teams of specialized tasks with relative independence from each other. In contrast, relatively “unstructured” (unpredictable) cases required higher-level coordinative leadership – the overall management of the context and allocations of priorities by a designated individual. Originality/value – Crisis medicine relies on designated leadership over highly differentiated personnel and unpredictable events. This challenges the notion of organic coordination and upholds the validity of a concept of leadership for crisis medicine that is not reducible to simple coordination. The intersection of predictability of cases with types of leadership can be incorporated into medical simulation training to develop non-technical skills crisis management and adaptive leaderships skills.
Conclusion
This study has illuminated the conditions that give rise to, and the indicators of a need to, transition from relatively independent teams featuring “distributed leadership” to more directive “coordinative leadership”. This does not mean that traditional “top-down” leadership is necessarily desirable in all medical crisis situations. The primary research agenda from this study is to ascertain the conditions under which organic coordination – characterized by minimal supervisory interference and valorized by proponents of postbureaucracy – can develop in a high-intensity interventional environment involving highly specialized “firsts among equals”. Research is also needed to compare these findings with other high-intensity and complex situations outside of health care such as disaster management. As suggested above, observational studies of team responses to changes in conditions of certainty are also needed to further our understanding of the “lived dynamics” of these ad hocteams.
As implications for policy, practice and education, we have learned that key to the success of a crisis intervention team is the ability of a leader to adjust to the various spatialcontextual, patient-based, role-based, experience-based and individual influences evident in this study, and still provide a shared mental model for the care of critical patients. This study demonstrates the variety of individual and contextual leadership skills needed in crisis intervention, such as traumas in the ED. These overlap depending on the degree to which the situation is structured, or unstructured, as circumstances are, or become, unfamiliar. Crisis interventions, in particular, require urgent intervention in often ad hoc teams. This raises the stakes for appropriate leadership – and the prospect of uncertainty. Crisis intervention teams need coordinative leadership – beyond the performance of tasks that individuals are taught to contribute from their unique and specific disciplinary roles or allocated roles. These can provide a benchmark for performance measures, both individually and organizationally, and indicate specific skills to target in simulation exercises of crisis resource management.
