Patients’ views of teamwork in the emergency department offer insights about team performance

Abstract

Background

Research into efforts to engage patients in the assessment of health‐care teams is limited.

Objective

To explore, through qualitative methods, patient awareness of teamwork‐related behaviours observed during an emergency department (ED) visit.

Design

Researchers used semi‐structured question guides for audio‐recorded interviews and analysed their verbatim transcripts.

Setting and participants

Researchers conducted individual phone interviews with 6 teamwork subject matter experts (SMEs) and held 5 face‐to‐face group interviews with patients and caregivers (n = 25) about 2 weeks after discharge from the emergency department (ED).

Results

SMEs suggested that a range of factors influence patient perspectives of teams. Many patients perceived the health‐care team within the context of their expectations of an ED visit and their treatment plan. Four themes emerged: (i) patient‐centred views highlight gaps in coordination and communication; (ii) team processes do concern patients; (iii) patients are critical observers of ways that team members present their team roles; (iv) patients’ observations of team members relate to patients’ views of team effectiveness. Analysis also indicated that patients viewed health‐care team members’ interactions with each other as proxy for how team members actually felt about patients.

Discussion

Results from both sets of interviews (SME and patient) indicated that patient observations of teamwork could add to assessment of team processes/frameworks. Patients’ understanding about teamwork organization seemed helpful and witnessed interteam communication appeared to influence patient confidence in the team.

Conclusion

Patients perspectives are an important part of assessment in health care and suggest potential areas for improvement through team training.

Introduction

Improving clinical teamwork enhances care with implications for all phases of health systems.1, 2, 3, 4 Salas and colleagues described a framework for effective teamwork among clinicians which highlighted five core components: team leadership, mutual performance monitoring, backup behaviour, adaptability and team orientation, as well as supporting and coordinating mechanisms.5 To characterize and improve health‐care team effectiveness, efforts have generally relied on trained observers or team member self‐report.6 Examples of measurement tools include the communication and team skills (CATS) assessment or the Mayo High Performance Teamwork Scale, among others.1, 7, 8, 9, 10, 11, 12 These tools provide clinicians and organizations with valuable feedback about their team skills and allow members to complete a reflective analysis of their team training.1 However, for the purposes of this research, they offer little information about how to engage the patient as participants in the care process and the ultimate end‐consumer most impacted by the presence or absence of teamwork.

Patient feedback and perceptions have been utilized in a number of health‐care contexts and have proven valuable. For example, the Agency for Health Research and Quality (AHRQ) established mechanisms for identifying and comparing patient‐reported experiences with health care through standardized, population‐specific surveys. A prime resource for public use, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), supports quality improvement efforts and facilitates comparison of results through the National HCAHPS Benchmarking Database.13 Through the HCAHPS survey, information gathered post‐discharge from patients about their care experiences can be obtained such as how well nurses and doctors communicate with patients and how responsive the staff is to patients’ needs. Also, patient questionnaires have been used to track results before and after staff development programmes to track change. In fact, when physicians were surveyed about how performance profiles from patient surveys helped to improve the quality of care they delivered, results indicated that specific profile items relating to patient satisfaction with interpersonal care and communication skills were the most important, and the most within their control to improve.14

While the value of patient feedback to individual physicians has been realized and is being incorporated into clinical training and practice, there is limited information about patients’ abilities to assess a team of providers. Previous studies partially addressed patients’ assessment of team functions, typically in the context of patient satisfaction questionnaires.15, 16, 17, 18, 19 For example, DeBehnke and Decker17 focused on patient perception of care coordination following changes in the structure of ED team members through analysis of the proprietary Press Ganey post‐discharge survey. Triolo et al.18 studied how to improve team performance through staff observations and patient views about interprofessional dynamics and verbal communication. Through analysis of comment cards during hospitalization and surveys 1 month after discharge (paper‐and‐pencil and telephone), researchers attributed that declining patient satisfaction was due in part to a lack of clarity about the role patients and family play as partners with the team.18 Fokkens et al.19 surveyed both patients and families at two time points, shortly after discharge and at 1 year post‐discharge to assess the impact of structured care processes on their view of team attributes such as collaboration, organization and leadership. Although organizations may not yet use patient input specifically to evaluate teamwork, these studies indicate that patients may be aware of and able to quantify health‐care teamwork‐related behaviours to some extent.

Qualitative methodology offers the opportunity to explore topics and add to our understanding of the phenomena of teamwork behaviours from the patient perspective in health services research.20 O'Cathain et al.21 used concurrent administration of interviews and focus groups in their design of the Urgent Care System Questionnaire (UCSQ) which aimed to determine patient perception of emergency care and the urgent care system characteristics of importance. Furthermore, they assessed the acceptability, validity and reliability of the UCSQ to measure patient views of urgent care and proposed use of this survey to measure quality improvement training of urgent care teams.22

The purpose of this study was to explore, through qualitative methods, patient awareness of teamwork‐related behaviours they observed during a recent emergency department (ED) visit. The ED offers a context for this research as multiple, and multidisciplinary, care providers interact with the patient over a short period of time. Our objective was to use these qualitative findings to identify themes surrounding patient observations of team behaviours and thereby enhance our understanding of team performance.

Methods

In this qualitative study, we employed an inductive process; thus, without a predetermined theory or framework,23 we used a problem‐oriented and real‐world practice‐oriented strategy to develop our research protocols.24 To explore a more complete description of patients’ awareness of team interactions, we drew our study sample from two populations25: (i) phone interviews with subject matter experts (SMEs) in the field and (ii) group interviews with discharged patients and caregivers. We obtained a fundamental understanding of patient‐reported experiences with health‐care teams by reviewing previous research. Planning and conducting the interviews and analysing data followed guidelines described by Morgan and Krueger26 and Boyatzis.27 Institutional review board approval was obtained for all research activities, and all participants provided informed consent prior to participation.

Study participants and setting

Two researchers independently reviewed the results of a literature search directly relating to health‐care teams, teamwork, physician–patient communication or patient safety within the past 5 years and concurred on a list of 10 potential SMEs. The aim was to include experts from each content area and a breadth of locales. The researchers sent the 10 SMEs, an electronic invitation to recruit his/her voluntary participation in a semi‐structured, audio‐recorded telephone interview with a brief explanation of the study purpose and process. Six SMEs scheduled an interview, one declined, two requested a later date, and for one, we received no response.

For the group interviews, a convenience sample of adult, English‐speaking, discharged patients and caregivers was recruited by research assistants (RA) who were periodically stationed in the urban, academic, level‐one trauma centre (annual volume = 85 000) based on peak timing of discharges and RA availability. During recruitment periods, RAs reviewed ED orders for home discharge to identify potential study participants, only excluding individuals on the basis of uncorrected hearing impairment that may have prevented them from participating or being too ill to participate (as reported by the patient or ED staff). RAs then approached those discharged patients or their caregivers still available in the unit and found 97 potential study volunteers (73 patients; 24 caregivers). To allow some recovery time from the illness that promoted their ED visit, a member of the research team contacted each volunteer by phone or email (up to four attempts) about 1 week after discharge to reintroduce the study purpose and procedures. Of this group, 38 volunteers (39% of the recruitment list) scheduled to return to the facility for a 60‐min group interview: two sessions were planned to include only patients, one for only caregivers and two sessions to include both patients and caregivers. The remaining 59 recruits were not available or no longer interested (33 had scheduling conflicts, 21 did not reply to scheduling calls, and five declined).

Data collection

Data were gathered using a semi‐structured format for SME and group interviews (see question guides in Table 1). Following consensus on study procedures, two researchers independently conducted audio‐recorded SME telephone interviews with an expected length of 30–45 min per interview. Efforts to verify participant viewpoints included an offer to distribute interview summaries for review by the SMEs. For each group interview, the moderator began with a presentation of ground rules, particularly regarding confidentiality and mutual respect for participant comments. The trained moderator asked participants to recall their experiences observing the health‐care team in the ED and encouraged them to express their ideas, expanding on direct questions while limiting their focus on individual medical treatments. A second researcher scribed field notes and summarized the discussion for participant verification. Group interview participants received nominal remuneration at the conclusion of the session. Data collection stopped once the research team reviewed participant responses and determined sufficient saturation of themes, and informational redundancy was achieved.

Table 1.

Interview question guides with follow‐up probes

SME interviews	Group interviews
How do teamwork behaviors impact patient outcomes? Positively…negatively? Specific to care in the Emergency Department?	Think back to your recent visit to the ED Your general impression about the ED workers as a team? Example of ED workers talking to each other or communicating about your care? What about the nurses talking to the doctors? newer doctors with more experienced doctors?
What teamwork behaviors patients may be aware of? What do the families see? Any differences between them?	What other interactions or behaviors did you see between the people who worked in the ED that took care of you? Were there times when ED workers seemed linked to each other in the work they did? In what ways did the ER workers act that showed you how they worked together as a team?
Of the teamwork‐related behaviors patients may see, which ones could patients be the best source of information about? Or would there be other ways to get this information? Ways to compare observations with other measures?	How would you describe the way people worked together in the ED to a friend or family member? Did it make a difference to you how the people in the ED work as a team?
Do you see any connections between teamwork behaviors patients may observe and domains of teamwork? Leadership Situation Monitoring Communication Mutual Support	Of all the things we discussed about interactions between workers that you saw during your visit to the ED, which one is most important to you? What makes it important?
Do you see any of these patient‐observed teamwork behaviors reflected in AHRQ TeamSTEPPS ® curriculum? Or other training programs?	Summarize the Discussion: key questions and big ideas that emerged How well does that summary capture what was said here?
Other tools that you know of to measure patient perception of teamwork‐related behaviors?	Is there anything that we should have talked about but didn't?

Data analysis

Data analysis to develop themes from the multiple perspectives (SME, patient, caregiver) occurred through a continuous, on‐going procedure as audio recordings, verbatim transcripts and field notes were reviewed using the constant comparative method.27, 28 The steps of analysis of the SME and group interviews occurred in concurrent though separate processes. Analysts who conducted independent review of verbatim transcripts included the two interviewers for the SME interviews and three analysts of diverse backgrounds (i.e. allied health professionals, including a new graduate, junior faculty and a senior physician) for the group interviews. The next step consisted of identifying coding labels for the ideas, concepts, terms, phrases or keywords in the transcripts to develop a dictionary of codes.27, 28, 29 Then, analysts within each interview source (SME or Group) met to develop consensus, reconciling differences about codes and discussing the frequency and intensity of coded comments for each data source to identify themes.29 After themes had been developed separately for both the SME interviews and the group interviews, the research team met to collectively compare and contrast emergent themes exploring connections between the coded data and themes across interview sessions.

Results

Two researchers independently conducted interviews with six SMEs. These professionals were drawn from the fields of team science and training (n = 3), communication (n = 2) and patient safety (n = 1), located in four regions across the United States and Canada (median interview time = 26 min).

For the group interviews, 25 of 38 scheduled individuals participated in one of five, 1‐h sessions (Table 2). Thirteen scheduled participants failed to show for their session for varying reasons (e.g. still too ill, caregiver unable to leave patient or unknown). Thus, while initial registration for group interviews consisted of five to twelve individuals per session, for two sessions only two participants attended and the desired mix of participants (patient to caregiver mix) was not achieved at one later session. The remaining three sessions included one session with five participants and two sessions with eight participants each. The last session remained purposefully composed of mainly caregiver participants (six of eight). When the sample was compared with ED statistics for that time period, it revealed slightly more female participants (68% vs. 56%) and shorter average length of stay in the ED (3.0 vs. 5.6 h).

Table 2.

Description of group interview participants

	N (%)
Characteristics
Male	8 (32)
Participant age (years)	48 (22–81)
Race/ethnicity
Black/African American	12 (48)
White/Caucasian	10 (40)
Hispanic/Latino	1 (4)
Native American	1 (4)
Mixed/Other	1 (4)

ED statistics	Mean (range)
Time spent in ED (hours)	3 (0.33–7)
Patients admitted to hospital	3

During analysis of SME and group interviews, factors that may influence patient awareness of teamwork in the ED emerged, and we categorized data using multiple codes and then reviewed the coded data to identify emergent themes. These findings are described here, first for the group interviews and then for the SME interviews.

A total of 12 codes were identified for the data from the group interviews: familiarity or being informed about the ED process; interteam communication; suggestions about teamwork; informed about team structure; repetition; interteam behaviours; reactions to teamwork observations; process/workflow of ED visit; general comments about team (positive and negative); confusion about team process; and patient's perception of their role on the team.

Three codes of comments reported most often or with the greatest intensity and widest agreement in group interviews are described here with related quotes.

Patients described a pre‐existing familiarity with the ED process and awareness of their own flow through the ED

• ‘I've been in the emergency room quite a bit over the past few months. There's a check‐in desk. Usually the nurses will see you first and then you'll see the doctor and registration will come in and gather your information and your insurance and everything and then you'll see the nurse again before you check out’.

• ‘I saw the nurse and the attending physician in the beginning and then training physicians’.

• ‘One of them came in and he said what he had to say in passing. I mean physically walking away; he said everything is negative… I understand [that is] the way they do business’.

Patients make assumptions about whether or not team communication occurred with and without directly witnessing it

• ‘Well you hear all kinds of conversations… Two of the interns taking care of me and the doctor came in, they interacted very professionally’.

• ‘I saw the charge nurse talk to the attending physician maybe a few seconds about the assessment and outside the patient room, the nurses seem like they hang with each other and talk to each other and the attending physicians and the students, they are in their own little group’.

• ‘So, the communication piece, that didn't happen, like when somebody leaves the room they don't tell the next person what they have done’.

Patients had strong opinions on how to improve teamwork behaviours

• ‘So, like who's in charge from beginning to end? It felt like a lot of different people coming in or out but no one was really owning your case. So, [it would be good] if there was just one person, whether it be a nurse or a doctor … who should be in charge… and give directions’.

• ‘Instead of having each individual come in and ask you the same thing if they would just communicate it would be a lot easier…. Teamwork if done properly creates far more efficiency than it seemed to be done’.

From the SME interviews, six codes were identified: influences on patients’ observations; the care process; the importance of the patient perception; interteam communication; coordination of care; and observations patients make. The two most commented on codes from SME interviews are summarized here with a sample quote.

Influences on patients’ views: patients’ prior experiences, diversity and cultural differences, degree of vulnerability (e.g. anxiousness, discomfort, fear, naivety, stress), age and whether the patient or caregiver perceived any ‘role’ on the team.

• ‘In general I think patients tend to not want to upset anybody because they're the vulnerable one in the bed and especially if you've got an older adult. I think patients that are younger have a more consumer driven approach are more critical; and you're expecting that people are communicating with each other … younger people are looking for evidence that they've been included in the planning’.

Awareness of team processes: patients’ observations will vary by their comfort and confidence with team interactions.

• ‘I really feel strongly that anxiety contributes significantly to the difficulty that patients encounter in terms of getting the information that they need and understanding what's happening … that in large part comes from [patients thinking] are they [the team] going to understand what I really want to tell them? …are they going to pay attention to what I really want to say, are they really going to work with the information that I know is wrong with me or what I perceive is wrong with me? And that I think causes some anxiety’.

Emergent themes

Analysts reviewed the 12 codes of data from the group interviews in conjunction with the six codes from the SME interviews and identified four overarching themes listed with representative quotes in Table 3. These themes include (i) patient‐centred views highlight gaps in coordination and communication; (ii) team processes do concern patients; (iii) patients are critical observers of ways that team members present their team roles; (iv) patients’ observations of team members relate to patients’ views of team effectiveness. Details of the themes as they relate to the patient/caregiver and SME perspectives are described below.

Table 3.

Emergent Themes from Interviews and illustrative quotes

Subject matter expert responses	Group interviews responses (patients and caregivers)
Theme 1: A patient‐centred views highlight gaps in coordination and communication
You can look at that from the team point of view as well as the patient point of view … if there's not somebody coordinating the care and the communication amongst team members … From the patient's eye, from somebody who is naïve to the context and whose stressed, who is scared all you want to do is get an idea of do these people know what they're doing? Patients are human beings and so patients and team members alike and family members alike will tune into those things [teamwork behaviors] far more astutely than anybody has routinely articulated	My only problem was the period in between seeing the nurse and the doctor coming in and then after talking to the doctor and him telling me whatever he wanted to say getting to the discharge part. There was like long gaps in between those two things. It was like I'd see…as soon as I got in the room I would see three people and then all of a sudden I would wait an hour or two hours and then finally a doctor would come in and then I wouldn't see him no more….and I waited for like another hour and a half before I got my discharge papers. I was actually there for 5 h, … I maybe saw someone three times in that 5 h period…..It seemed like everybody was just kind of sitting around and I just couldn't figure out why, you know, I got my x‐rays and no one really came in to tell me anything about it until about an hour and a half to 2 h later….why would it take 2 h for them to read the x‐ray. That I thought was kind of bizarre. …so frankly, I was there for 3 h before I really got seen and I thought that was unreasonable
Theme 2: Team processes do concern patients
[worry about when patients ask] Is anybody in charge? Yeah, like who's got this?…who's looking out for me? Whereas I think if you come in and you're asking questions that clearly they've already answered to somebody else that tends to generate anxiety and at times frustration for them and I think in that way because anxiety and frustration are not ideal feelings to make a person then accessible to information, accessible to the acquisition of new knowledge can impede that process. When the left hand doesn't know what the right hand is doing…. No matter how well we are communicating potentially with each other outside the door, if that's not being conveyed to the patient there is still a failing in our team work, right?	My personal opinion…there was what appeared to be a lot of teamwork but really it was a lot of duplicitous…somebody coming in asking me the exact same question you know even though I had hit my head it was the same question over and over as opposed to…and it just felt like I was getting a new person each time as opposed to it necessarily being teamwork related where somebody was going to retrieve somebody that had come answer my question. I just felt like I was answering starting over again, again and again and again. [They asked] what was the problem, and wrote it down, so then they went and told the next person. That person come in and quoted what the first person told you versus going to who is in charge and that person comes and tells you and gathering all those notes together they have an idea of what is going on. They have an idea of what is going on. There are like 100 rooms or whatever or who is the keeper of the chart or it should be right in the room so they could just look at the chart and see what is going on. [If the information is in the computer] then, why do they ask us? Maybe that's the problem with the team, or why the teamwork's not happening. There is no method for them to communicate the information to their team members
Theme 3: Patients are critical observers of ways that team members present their roles on the team
Helpful to know who to speak up to. So picking up who is in charge that might be a good skill to have because as a patient, or have some knowledge of that because then you know…then I know when I need to speak up about something that I don't feel comfortable or that as a patient I need clarity. Right, I know Sally's at lunch and I'm taking her patients or I know Sally is tied up down the hall I'm watching her call light for her. So that the patient sees that their safety net is more than one person deep	Otherwise you are just a laying there going, what the heck is going on? and listening to everyone else's conversations about their hair, you know. You are wondering, like seriously, I am in here in extreme pain and you are talking about your recipe for Thanksgiving, you know? I think the attitude towards us as well as people they are working with behind the curtain are equally as important because if this doctor is yelling at the medical student or … if you're listening to the attending physician talking to a medical student or another patient in a way that is demeaning then how much do you really believe that they are actually caring about you once he gets in with you? I mean, it is like okay, suddenly you really care about me, but you didn't care about that poor person that was over on the other side and you didn't really care about the feelings of the medical student you just reamed in front of everyone, so when you come in to talk to me, do you really care about me? I really kind of doubt it
Theme 4: Patients’ observations of team behaviours relate to patients’ views of team effectiveness
The patient will definitely have a sense if the nurses and physicians especially …respect each other, are valued… Like there is something about the team that I think the patient knows that there is something about this team that works well. And I feel safe with them. I think that they can see that. Through all of this is the patient's ability to see and hear and observe conflict. Which obviously is the worst end of teamwork. I don't there are any questions that the patient can bring important perspective to team functioning	From my experience, they all seemed really in step with each other. They were all very friendly with each other. They seemed to communicate really well. Knew each other very well. The tones that they used in speaking with, not only myself, but if they needed to communicate with a different staff person, it was a pleasant tone, pleasant manner. If they are joking with each other, they are probably going to be really friendly and patient with you The first person, which was the triage nurse, I don't know if it was just that she was stressed, but you could hear the friction or her not being pleased with what was going on. She was pretty short and kind of snappy…. It made me uncomfortable

Theme 1: Patient‐centred views highlight gaps in coordination and communication

When asked about teamwork behaviours, patients responded with comments that described their overall ED experience, and their analysis of the quality of the visit was the lens through which they viewed their care team. The patients frequently commented on general processes and delivery of care (e.g. length of stay, condition of the waiting room, swiftness of receiving pain medication or interpreting x‐ray results) rather than specific components of teamwork, such as leadership, back‐up behaviours or shared mental models as noted by the SMEs. Considering the patients’ comments in the light of the distinctions made between taskwork and teamwork by McIntyre and Salas, these patients focused more on taskwork directly related to their own treatment.30 Also, participants frequently attributed wait time, length of stay or treatment delays as being related to teamwork rather than overcrowding or operational priorities. This patient‐centred view did not specifically address observed team behaviours, but highlighted how the patient is experiencing the team – with intermittent interactions and resulting gaps in coordination and communication.

Even though selected for their expertise in the field, each SME also spoke about his or her own personal experiences and observations as a patient or caregiver. Thus, despite their professional role, some of the most memorable experiences of teamwork for these SMEs were their own as patients. This contributed to both the first theme regarding the patient perspective and the second theme about team processes. Notably, each SME explained the commonalities between patients’ views and team members’ views. Some variability in patients’ views was attributed to factors such as understanding of the ED environment, exposure to team interactions and degree of illness.

Theme 2: Team processes do concern patients

Patients seemed very interested in how the team worked, and in cases where the care processes were not explained, patients frequently made their own assumptions about team functioning, potentially undermining their confidence in the team. Interprofessional dynamics, team interactions happening in the patient room or within the unit, were a significant focus throughout the group interviews. Although many described the ED as loud and chaotic, patients were cognizant of the interactions between care team members, not just pertaining to verbal communication, but also in affective qualities such as tone of voice and general demeanour.

Also, the SMEs endorsed the value of determining patient perceptions about teams. They readily described team functions that may influence patient outcomes including the teamwork‐related behaviours patients might observe. The list of teamwork tasks included several items noted in team‐training curricula, such as Crisis Resource Management and TeamSTEPPS ^®.10, 31 For example, SMEs listed team behaviours that may be noted by patients such as communication, coordination, collaboration, role clarity and conflict/disruptive behaviours currently incorporated in training programmes. Also, the SMEs universally suggested that work in this area of research is needed, as patients’ and caregivers’ observations of team behaviours may relate to patient outcomes, and their perspectives are currently not being captured. They also suggested that caregivers may be even more aware of team interactions than patients.

Theme 3: Patients are critical observers of the way team members present their team roles

It also became evident that there is a need for explicit communication with patients about team process and team roles. Patients frequently described their confusion about procedures regarding changes of shift and how individual providers fit into the multidisciplinary care team (i.e. ED attending and resident physicians, nurses, technicians). Patients reported that explicitly defined team roles and verbalization of the overall course of care helped set expectations and optimize communication throughout the visit. Although patients were not always correct in their assumptions of teamwork, they expressed beliefs that the team impacted their care and were concerned about team operations.

SMEs anticipated some of the confusion and frustration that the patients and caregivers also expressed about teams. They described potential feelings of uncertainty or lack of security that a patient may feel if he or she was unclear of team members’ roles while providing care. The SMEs made suggestions about how teams could enhance care and ease patients’ confusion about health‐care teams, including (i) setting expectations for the ways teams coordinate care; (ii) explaining teamwork organization and leadership to increase transparency; and (iii) facilitating open communication.

Theme 4: Patients’ observations of team members relate to patients’ views of team effectiveness

The awareness of and interest in interprofessional dynamics noted in Theme 2 led directly to the fourth identified theme. Specifically, a common assumption was that if patients observed providers being nice to one another, they considered the team to be functioning well and gained trust and confidence in their care. However, the converse was also true: if patients witnessed negative interteam behaviours, it affected their confidence and trust in the team. In fact, some participants even expressed a lack of trust in the treatment plan or cynical view of the ED teams’ empathy because of negative conversations they overheard.

SMEs also anticipated that it may be undermining to patients’ confidence if they observe internal team conflict or a lack of respect among team members.

Discussion

Through this research, we investigated perspectives of patients/caregivers and SMEs to explore a more complete description of patients’ awareness of teamwork‐related behaviours. The patient‐centred view of teams, as described above, makes it clear that many patients do compare their experiences with their expectations of an ED visit and how an ED should function. As demonstrated in the group interviews, patients largely responded to questions regarding teamwork with answers focused on the overall processes of care, delivered in the context of their own expectations. Also, patients revealed characteristics of teamwork they considered to be important.

Results from SME interviews highlighted various factors that may influence patient ability to distinguish observations of teamwork‐related behaviours from their care experiences, ranging from attributes such as age and illness to relationship with the team. As noted above, we found that patients developed their views about teamwork from direct observations as well as their own assumptions. Previous studies looking at patient expectations of ED wait times have shown that a simple explanation of the triage process improves patient satisfaction.32 Perhaps a similar description of the ED team would also impact patient perceptions of how providers work together to deliver care.

The four themes described above offer a new vantage point for thinking about the assessment of teams. Although these patients’ comments about teamwork behaviours were mixed with views of their overall ED experience, they did show the ability to observe team behaviours. The results provide evidence that patients make assumptions about the team and the clinical environment. Left unguided, patients may impose unrealistic models from their own perspective of how the team functions and make assumptions regarding the quality of team members assigned to their care. While the extent of patients’ observations varied, the division between positive and negative behaviours and how they felt connected to the team was evident. At times, patients noted a lack of coordination or confusion about team roles and functions, leading to a sense of frustration. In contrast, when clinicians introduced themselves and their roles, patients felt favourable towards the team and, in concert with this, confidence in their treatment.

A gap in our understanding of teamwork through the lens of the patient's perspective may have deleterious downstream effects. Despite suggestions from some of the SMEs that the patient needs to perceive a role on the team before they can observe care coordination and teamwork, only at the group interviews with caregivers did the perception of patients having a potential role on the team arise. This raises the question that if patients participated more actively with the care team, would they be less likely to make sometimes negative assumptions about teamwork‐related behaviours? Results from both SME and group interviews did suggest that explaining ED processes to set expectations for team‐coordinated care could ease patients’ concerns and confusion and enhance their confidence in the team. Also, the findings of this study suggest that witnessed communication may influence patient confidence in health‐care professionals – either to bolster or degrade it. Some participants indicated that their view of health‐care team members’ interactions with each other served as proxy for how team members actually felt about patients.

Besides efforts to alter patients’ perceptions, an ultimate concern is the potential to impact patient outcomes. Previous literature correlating patient confidence in clinicians with their likelihood to fill prescriptions demonstrates that patients are less likely to follow‐through with even simple, achievable and explicit instructions if they lack confidence in the prescriber.33, 34 Thus, although we did not consider the diagnosis of our patients, our findings suggest that if a patient observes negative behaviour between and among clinicians, the possibility that the patient will follow discharge instructions may be diminished. This is particularly relevant in the fields where interprofessional dynamics are on display, such as the ED. As investigators seek translational evidence, studying the relationship between patient views of team behaviours and patient outcomes with team‐based care may yield a significant new set of learning objectives directed specifically towards building patient confidence through team interactions.

The literature regarding teamwork shows that although the patient may be the central focus of the team process, as yet there are only a few patient perspectives included in the evaluation of team performance.15, 16, 35, 36 SME comments confirmed that the patient view is notably absent in most team‐training programmes and the concept that the patient's outcomes may be affected by witnessed behaviour is not currently in the team‐training lexicon. The results of our study provide indicators for staff training as did prior qualitative research to describe patient perception of urgent care systems.21, 22 Although patients are often treated as a source for information and a depot for updates, programmes rarely engage the patient as a core team member. In contrast to the medical model of determining patients’ needs, interviews of lay groups about patient‐centred care indicated that patient involvement in planning and delivery of health services is important.37 Some guidance may be offered by the division of major components of teamwork‐related behaviours as taskwork (‘work done by an individual, or group of individuals, behaving autonomously rather than interdependently’) and teamwork (‘behaviours that coincide with team members’ interacting to achieve desired goals’) (p.33).30 In our results, patients spoke first about the treatments they received, and current patient surveys are designed to gather this feedback. Our participants also remarked on interactions between team members. Using patient input with both treatment and teamwork evaluation may help improve team performance.

Limitations

Interpretation of these results also include acknowledgement of study limitations. For the interviews, efforts to limit the bias in participant selection and responses were made. However, the availability of SME volunteers, availability of RAs to recruit participants for group interviews during daytime hours and follow‐through with attendance at group interviews potentially impacted study results. Factors that may have influenced discussion at the semi‐structured group interviews included the following: patients’ wanting to appear in support of their ED or not wanting to appear too critical; a low number of participants at two of the group interviews; and the challenges of memory recall of the prior visit when ill. In an attempt to limit the impact of these factors on our study, we encouraged diverse viewpoints, during analysis, we compared themes from different groups, and the smaller interview groups did not reveal any notable differences from the well‐attended group sessions, and we held group interviews within 2 weeks after discharge. We recognize that patients’ views over time can diminish or be altered, as with other post‐discharge surveys.

While interviews offer participants the opportunity to recall information, an acknowledged limitation is also that they are responding to a line of questioning. Efforts to verify the neutrality of study findings and minimize the potential of response bias included the following: (i) data collection and analysis were distinct steps of the project, including member‐checks with each session; and (ii) the moderator practiced asking interview questions prior to group sessions to establish a process that showed we did not have expectations about participants’ responses and wanted to encourage open dialogue.

Despite these limitations, the findings of this study have potential implications for clinical practice and future research and merit consideration. First, future research should explore what patient observations of team‐related behaviours can mean to the health‐care system, and what our ignorance of it implies. Second, further research is needed to find out how reliably we can assess teamwork in a unit based on patient observations. As indicated by the SMEs, it could be helpful to consider these results from a training perspective. As described by others, both patient communication with teams1, 38, 39 and interteam processes can influence patient outcomes.6, 7 The results of this study suggest we may be able to further improve care quality by engaging patients in team assessment.

In conclusion, the results of this research offer support for incorporating the patient perspective into the assessment and enhancement of clinical teamwork. The complex issues inherent within the ED make it an opportune environment to investigate how patients recognize teamwork‐related behaviours and how they respond to their observations. Furthermore, the teamwork‐related behaviours highlighted in this study as problematic for patients merit further attention in team training and development of communication skills.

Funding

Not applicable.

Competing interests

None to disclose.