Coronavirus disease 2019 (COVID-19) has brought unprecedented stress to society at large and perhaps most of all to frontline healthcare teams in a variety of settings.1 Although a crisis “can stimulate some people’s willingness to cooperate […] the incessant stress present during a crisis makes it significantly harder for teams to sustain coordinated performance over time.”1
To address the challenges of managing teamwork during the pandemic, we spoke to Allison Traylor, MA, a PhD student in Industrial Organizational Psychology at Rice University, Houston, Texas and coauthor of “Managing Teamwork in the Face of Pandemic: Evidence-Based Tips”, which appeared in BMJ Quality and Safety.1
What informed the review you coauthored?
The lead author on our article was Scott Tannenbaum, PhD, who is the President of the Group for Organizational Effectiveness. The other coauthors were Eduardo Salas, PhD, chair of the Department of Psychological Sciences at Rice, and Eric Thomas, MD, MPH, Professor of Medicine, McGovern Medical School, University of Texas Health Science Center at Houston.
Over the past 3 decades, scientists have researched teamwork in times of crisis. The review authors have advised teams in a variety of different settings, medical and otherwise, and have studied the increasing body of research on team effectiveness. Many of these industries involve high pressure serious consequences of failure, such as astronauts, deep-sea divers, jet fighter pilots, smokejumpers, miners, EMTs, soldiers, and trauma teams.
1. Celebrate all successes-big and small
2. Make sure team members understand their roles and priorities
3. Don’t overlook anyone, including team members who work behind the scenes
4. Encourage mutual team monitoring and support
5. Foster psychological safety
6. Help team members identify and address concerns within their own lives
7. Consciously boost team resiliency
Based on 50 meta-analyses on team effectiveness and the personal experience of the authors, we decided to address the urgent need for team effectiveness during this time of COVID-19.
What types of stressors does COVID-19 pose to healthcare teams?
COVID-19 creates stress on multiple levels; individual, team, organizational, and work-life.
On an individual level, healthcare workers may feel concerns about their own health, or that of their families. They may also feel overworked, fatigued, or burnt out.
Team-level stressors include lack of team member expertise—for example, when people have to assume new roles—as well as unfamiliarity with new team members, increased consequences of mistakes that both team members and patients will experience, and new or unfamiliar processes or procedures.
On an organizational level, insufficient resources, such as PPE and ventilators have been a major challenge.
Large healthcare systems as well as individual medical practices face enormous financial repercussions of COVID-19. Elective procedures and outpatient visits have plummeted, resulting in loss of revenue to hospitals as well as practices.2,3
Finally, work-life stressors, which are difficult to navigate even at the best of times, take a toll during COVID-19. These include concerns about family and friends, financial concerns due to unemployment or furlough of family members, and social isolation.
What impact do these stressors have on teams?
We feel that these stressors lead to both attitudinal and behavioral risk points.
Attitudes and cognitions of concern include low belief that the team can succeed (sometimes referred to as loss of collective efficacy); narrowing of attention, with excessive focus on oneself, insufficient shared mental models, such as roles and priorities, and discomfort speaking up, which creates a sense of lack of psychological safety.
Additional issues are that schisms may start to appear among team members, there may be insufficient vigilance, and people may fail to ask questions, admit concerns, or provide feedback. Perhaps most importantly, when setbacks occur, they adversely affect the next tasks, creating low team resilience.
To mitigate these effects, our team identified 7 recommendations for organizational and team leaders as well as team members to deal with these stressors and mitigate their negative impact.
Celebrate all successes-big and small
During the pandemic, teams may be struggling to maintain collective efficacy, which is having a shared sense that you can achieve your goals. In the healthcare context, this means helping patients get through COVID-19 and come out alive and healthy on the other side. It’s really easy to lose collective efficacy when you are consistently confronted with failure, such as high patient mortality rates, but sharing successes boosts morale and can lend perspective.
For example, if a healthcare provider has had losses of patients during his or her shift but hears good news coming from other teams in the hospital about successes in treating patients, this can suggest that, although one team is experiencing discouraging results, other teams might be experiencing more successes and this can give hope that successes are happening and can happen in their team as well.
I have heard about hospitals where, if a patient with COVID-19 has recovered and is discharged, all the nurses, physicians, and patient care staff stand in the hallways to cheer them out. This is a good example of building collective efficacy and taking a moment to celebrate every victory.
Make sure team members understand their roles and priorities
“Shared mental models” (SMM) are also called “team cognitions” and refer to a team’s shared, accurate, and complementary understanding of their domain, which enables teams to adapt and coordinate together. This can be accomplished through regular huddles and debriefings, even if time is limited, as it is during the pandemic. During these often-brief meetings, roles and priorities can be clarified, and it can be determined who has the most expertise to take on a given need.
Don’t overlook anyone, including team members who work behind the scenes
Many of the healthcare professionals who are working with COVID-19 patients are visible and providing hands-on treatment. They are the face of the “healthcare heroes” and are justifiably lauded and appreciated. However, it is very easy to forget the number of people behind the scenes, including those who obtain supplies or monitor the need for supplies, those who answer phones or those who are working with patients who do not have COVID-19. In this type of setting, communicating the wins and success of all members of the practice, including those in the background, allows a sense of collegiality. Sharing the workarounds people are coming up with for problems helps improve the learning of the entire team over time.
The “schisms” I mentioned earlier refer to the sense that there is a hierarchy of importance, with those providing direct COVID-19 care more important than others in supporting roles or who are not providing care to COVID-19 patients. This can cause a sense of having people feel unappreciated. All contributions to the functioning of the healthcare system or practice should be regularly acknowledged and commended.
Encourage mutual team monitoring and support
A major concern that we have seen is a narrowing of attention,4 which means that people on a team can over focus on themselves and their own jobs and not take a step back and see the larger team, so mutual team monitoring is critical. Some research5 has suggested that effective teams successfully monitor the situation itself, team performance as a whole, and each of the teammates.
Team members should be encouraged to provide back up to each other if one person seems overwhelmed or fatigued. Leaders might encourage situation monitoring, for example, if an individual has an excessive case volume, or performance monitoring. More experienced team members can also lend support to less experienced team members.
Foster psychological safety
One of the most important emphases of our review is how teams should discuss failure so that it leads to improvement. A crucial component of this is a sense of psychological safety for all team members, which is feeling that it is safe to speak up in your team and voice your concerns, even regarding mistakes that you or another team member might have made. In fact, psychological safety is one of the strongest predictors of team success.6
This is particularly important in high-stress, rapidly-moving situations, such as the pandemic, where team leaders must rely upon team members to speak up and ask questions. In teams where there is a leader who is not receptive to feedback, people are afraid to speak up about things that have gone wrong. We recommend across the board for leaders and team members to be open and honest about where you can improve, do not try to act like you know it all, and recognize that everyone is learning how to do things along the way.
Also, it is important to thank team members for speaking up, even when they are expressing dissenting views or admitting mistakes, and certainly not chastising or punishing them for their mistakes.
Psychological safety is important not only during the heat of the crisis but afterwards, when the team needs to be able to discuss honestly what happened during the crisis and establish the “new normal” going forward.
Help team members identify and address concerns within their own lives
Team members are not functioning in a vacuum. They have a “home team,” so to say, in other words, their own family and friends. Thinking about family and friends can become a source of stress and distraction when team members are in their professional setting. Especially during the pandemic, concerns about potential contagion to family members or concerns about financial, childcare or healthcare at home can compromise high-level vigilance.7
Identifying and acknowledging these external stressors and perhaps offering financial, informational, practical, or emotional assistance can be helpful. Although the pressures are higher and resources lower than they are in ordinary times, senior leaders and crisis management teams should try to find ways, even small ones, to offer support and practical assistance, if possible.
This applies not only to team managers, of course, but to team members as well, who can look out for each other. Part of this role includes being a good listener and also not offering glib or empty reassurances. I think that most team members have indeed shown good listening and empathy for each individuals’ struggles outside of the workplace and it is important to encourage that.
Consciously boost team resiliency
The term “team resilience” refers to the capacity of a team as a whole to withstand and recover from adverse situations and is somewhat different from individual resilience.8 Individuals who personally withstand pressure may not necessarily monitor or support other team members who are under stress.
Increasing team resilience involves anticipating and planning for stressful situations, providing mutual support, helping team members to move smoothly between “normal” and “emergency” modes, and between surges and more quiet times. It also involves identifying strategies that are not working or need improvement, and apologizing for hurtful behavior that might have taken place during a time of stress and crisis.
Effective teamwork is one of the most important ways for us to continue navigating the unprecedented set of challenges posed by COVID-19. It is our hope that our review will provide some guidance about how to do this, and that these approaches will be helpful not only during the immediate crisis of the pandemic but also during the aftermath and going forward.
1. Tannenbaum SI, Traylor AM, Thomas EJ, Salas E. Managing teamwork in the face of pandemic: evidence-based tips [published online ahead of print, 2020 May 29]. BMJ Qual Saf. 2020. doi: 10.1136bmjqs-2020-011447.
2. Barnett ML, Mehrotra A, Landon BE. COVID-19 and the upcoming financial crisis in health care. NEJM Catalyst. April 29, 2020. Available: https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0153. Accessed: June 24, 2020.
3. Rubin R. COVID-19’s crushing effects on medical practices, some of which might not survive [published online ahead of print, 2020 Jun 18]. JAMA. 2020; doi: 10.1001/jama.2020.11254.
4. Driskell JE, Salas E, Johnston J. Does stress lead to a loss of team perspective? Group dynamics: theory, research, and practice. APA PsychNet.1999;3:291–302. https://doi.apa.org/doiLanding?doi=10.1037%2F1089-2618.104.22.1681
5. Tannenbaum S, Salas E. Teams that Work: The Seven Drivers of Team Effectiveness. New York, NY: Oxford University Press In press, 2021.
6. Frazier ML, Fainshmidt S, Klinger RL, et al. Psychological safety: a meta-analytic review and extension. Pers Psychol. 2017;70:113–65.
7. Smallwood J, Schooler JW. The restless mind. Psychol Bull. 2006;132:946–58.
8. Alliger GM, Cerasoli CP, Tannenbaum SI, et al. Team resilience: how teams flourish under pressure. Organizational Dynamics. 2015;44:176–84