teamwork in the intensive care unit ( icu ) refers to the leadership , decision - making , communication , and coordination behaviors used by multidisciplinary team members to provide patient care .
patient safety research has demonstrated the importance of effective teamwork for ensuring positive patient outcomes in the icu .
poor communication during rounds and handovers ( or handoffs ) is frequently cited as a cause of medical error [ 2 - 4 ] , and units with high levels of nurse - doctor collaboration have improved patient mortality rates and reduced average patient length of stay . in attempting to understand and improve teamwork in the icu , researchers cite teamwork models and training techniques used to manage and improve teamwork skills in aviation . like work environments in aviation ,
the icu is a complex , high - risk , and stressful setting , and it can potentially gain from adopting and integrating the principles and techniques used to train team skills in aviation .
we consider the case for this and reflect upon the similarities and differences that exist between aviation and intensive care .
the aviation model of teamwork draws heavily from social and cognitive psychology and is based on an understanding that team behavior can both cause and protect against error .
it considers the team - related ' active failures ' ( for example , failures to communicate the proximity of nearby aircraft ) and ' latent failures ' ( for example , lack of team training , poor ergonomic design , and organizational culture ) that influence behavior and error in the cockpit .
psychology concepts relating to communication , shared decision - making , leadership , team cohesion , team mental models ( shared knowledge structures for teamwork and taskwork ) , and team climate are applied to understand performance and error . through the use of systemized models , these various concepts are bound together to explain how ' team processes ' ( for example , leadership and communication ) predict ' team outputs ' ( for example , error and team effectiveness ) .
furthermore , shared knowledge structures and ' team inputs ' ( for example , group hierarchies and culture ) are shown to influence teamwork behaviors , and safety culture is particularly significant . to understand the specific team behaviors important for safety in aviation , human factor specialists have performed cognitive task analyses , error analyses , attitudinal surveys , observational studies , and ergonomic assessments .
these data have structured the content of team training packages   and have contributed to the identification of teamwork knowledge , skills , and attitudes that underpin effective team performance ( table 1 ) .
training and assessment in aviation focus on improving communication skills , briefing behaviors , self - critique , leadership skills , workload management , vigilance and stress management , knowledge of team member skills / roles , and attitudes toward teamwork .
teamwork research in the icu has shown that the systems and concepts used to understand team performance in aviation are also relevant for patient safety in intensive care medicine . however , although team training has become increasingly common within the icu , much can be learned from the aviation industry 's advances in developing and integrating into practice the systems for measuring team behavior , providing feed - back , and developing teamwork skills .
team knowledge , skills , and attitude competencies this table , adapted from baker and colleagues   and salas and colleagues , is original and has not been reproduced elsewhere . in aviation ,
team training is mandatory for commercial pilots in europe and the us . virtually all large airlines use team training packages .
these use a combination of simulation and class - based training to help aircrews ( a ) prevent errors from occurring , ( b ) identify and trap errors , and ( c ) mitigate the consequences of error .
the aviation model provides aircrews with ongoing team training ( for example , annually ) and uses established pedagogic models to evaluate effectiveness .
such programs have a demonstrable impact on the attitudes of participants toward teamwork , teamwork behaviors , and knowledge of human factors .
validation of crew resource management skills is a training requirement throughout the aviation industry , and best practice is determined by regulators . despite evidence that the importance of team training is widely accepted in health care , it has not been adopted uniformly and the number of teams that regularly participate in training is still small .
key to the success of team training tools in health care is the identification of the domain - specific team skills required for effectively managing routine and emergency scenarios . in aviation , training strategies have focused on improving the skills required by aircrews to maintain effective decision - making under high levels of stress .
techniques include exposing teams to high - stress situations , training pilots to facilitate team discussions before and after stressful team activities , and cross - training aircrew team members to understand the demands and needs of one another 's role .
teams are trained in a multidisciplinary environment ( for example , pilots and cabin crew ) to facilitate an understanding of the challenges associated with different professional roles , to consider how group hierarchies influence behavior , and to develop expectations for behavior during different scenarios .
this training helps aviation teams to form shared and positive perceptions on teamwork and stress management . to assess performance ,
these tools assess teamwork through observable behavioral indicators that indicate good or poor aircrew team skills .
assessment and training can occur at either the individual or group level , and structured qualitative feedback is provided to participants .
it is clear that the team training and assessment techniques used in aviation are relevant to the icu .
for example , in the icu , as in aviation , hierarchical team structures have a negative impact on the attitudes and behaviors of doctors and nurses and , in turn , on patient safety .
furthermore , a range of teamwork and leadership behaviors important for team performance and patient safety have been identified . in terms of applying this knowledge to formal team training programs , courses such as advanced trauma life support
teach team skills and may provide a model for introducing team training into the teaching curriculum .
training would consist of general principles underlying optimal team performance in the icu ( for example , communication openness ) and also the behavioral strategies associated with specific practices ( for example , resuscitations ) .
table 2 notes the key stages associated with implementing an organization - wide team training program .
key stages in the design and implementation of a team training program   this table is original and has not been reproduced elsewhere .
key difficulties in developing such a program would likely be related to the resources involved in managing a comprehensive team training program ( for example , trainers , simulators , and clinician time to participate ) , ensuring that programs are consistent across intensive care medicine , avoiding duplication with other team training programs ( for example , anesthesia ) , generating intuitional support for team training , and identifying the key team training requirements for multidisciplinary icu teams . to develop team training programs for the icu ,
it is necessary to consider the extent to which the models used to conceptualize team performance in aviation can be applied in intensive care medicine .
as discussed above , parallels have been made between teamwork in aviation and intensive care .
icu teams are also reliant upon teams that manage risk , complex technologies , changeable workloads , and uncertainty .
fatigue and stress are known to negatively influence performance in the icu , and non - technical factors such as team communication , situation awareness , and decision making frequently underlie error
. however , there are also a number of general critiques that can be made in the comparisons drawn between aviation and health care [ 24 - 26 ] . for example , owing to the catastrophic consequences associated with in - flight safety failures , there are positive perceptions ( and a general awareness ) of safety culture throughout aviation .
in addition , medical errors often influence only a single patient ( and their family ) and , except in cases of negligence , the outcomes rarely impact other patients or health - care providers .
furthermore , aircrews typically manage stable interlinked systems that operate within expected parameters , and emergency events occur when the functioning of these systems is threatened .
they must tolerate high levels of risk and develop an ongoing understanding of the complex interactions between medical treatments and patient physiology . in regard to differences between aviation and the icu , a number of further distinctions can be drawn ( table 3 ) . it is notable that comparisons between aviation and acute medicine often focus on the domains of anesthesia and surgery .
this reflects similarities in procedures with aviation ( for example , pre - operative checks , induction , extubation , post - operative checks , and awakening ) .
however , the organization of work in intensive care medicine limits the extent to which these parallels can made .
for example , unlike aviation work environments , icus consist of large medical and nursing teams that care for numerous patients simultaneously .
problem solving is key , and teams must diagnose poorly understood patient illnesses , stabilize the condition of patients , and stimulate recovery .
team members have minimal prior knowledge of patient histories , and patient populations are diverse in terms of demographic background , risk factors , and underlying pathology .
key similarities and differences in the challenges faced by intensive care unit and aviation teams this table is original and has not been reproduced elsewhere .
in addition , the flow of work in the icu differs considerably from that in aviation .
for example , within a single icu , teams will perform a diverse range of hands - on , problem - solving , and monitoring tasks . in comparison , aircrews typically monitor and adjust a stable system in which outcomes are usually clear ( and positive ) , and team and task skills are essential for avoiding or managing emergency situations .
problems in aircraft technical performance are often raised through automatic warning systems , and periods of activity tend to be discrete ( for example , a 12-hour flight ) . in the icu , length of patient care is frequently undeterminable , and the duration of stay depends on the likelihood that patients will experience a sudden deterioration , the stage of treatment , and system factors within a hospital ( for example , available bed spaces ) .
patient outcomes are often unclear , and approximately 20% of uk patients do not survive intensive care . furthermore , patient care within the hospital system does not cease when a patient is discharged from the icu , and patients may return .
numerous clinical and nursing staff may provide patient care , and continuity of care is maintained through regular handovers . while these are key to maintaining the quality and safety of care , they can be un - standardized and subject to error .
furthermore , an icu will typically have several specialists leading the unit , and compared with their counterparts in aviation , each has substantial autonomy in terms of leadership style and preferred operating procedures .
this can result in inconsistencies ( between specialists ) in their expectations for the standards and procedures used to manage patient care and in their expectations for teamwork behaviors and attitudes . despite these differences , intensive care and aviation teams
they are multidisciplinary in nature and exhibit clear differences in the expertise and authority of team members .
furthermore , team performance is influenced by factors such as team leadership and shared cognition , and lessons can be drawn from the psychology literature on error avoidance and performance - enhancing strategies .
it is notable that both icu specialists and pilots believe in the importance of teamwork for safety and reject steep team hierarchies .
however , in comparison with pilots , icu specialists are less likely to report making errors ( or to feel comfortable discussing error ) , and they tend to have overly positive perceptions ( compared with junior team members ) toward team communication .
furthermore , although both aviation work environments and the icu are highly stressful , intensive care specialists are less likely ( than pilots ) to acknowledge the detrimental impact of factors such as stress and fatigue upon safety and performance .
senior intensivists are generally considered ' expert ' in the icu , and the majority of medical staff are in a training role .
trainees perform much of the hands - on clinical work and must learn to coordinate with nursing teams that have their own team structures , hierarchies , and levels of expertise . at an advanced level
, trainees must learn to manage the icu on their own ( for example , at night ) .
although senior intensivists are available to provide support , the thresholds for requesting help can depend on the trainee 's disposition to solicit help and on perceptions of the senior intensivists ' attitude toward false alarms .
a further difference with aviation is the participation of other actors in ' operational ' decision - making .
for example , patient decision - making in the icu can be influenced by non - clinical staff ( for example , patients and families ) and colleagues from other departments ( for example , surgery ) .
however , like aviation teams , icu teams regularly work with colleagues in other departments ( for example , surgery , microbiology , and radiology ) .
cockpit crews must also coordinate with teams in disparate locations ( for example , air traffic control towers ) . yet in the icu ( and in healthcare in general ) , the lines and protocols of communication between hospital units are often informal , un - centralized , and fragmented .
an additional parallel between the icu and aviation is the reliance on protocols to ensure safety and quality . in the icu
, a range of technical protocols are used to structure patient care and ensure safety .
aviation teams also use numerous protocols ( for example , pre - flight checks ) , and within the icu the emulation of aviation - style protocols to improve patient handovers has been shown to have positive outcomes . however , owing to high levels of uncertainty associated with icu patients , clinical judgment remains key for determining patient treatments and outcomes , and the extent to which it is desirable to extend protocols to aspects of teamwork and decision making is unclear
. finally , the use of simulation in icu training is increasing , and this will help to facilitate the adoption of the multidisciplinary team training methods used in aviation .
on the surface , the aviation model does provide a strong initial platform against which to design and implement team training programs for the icu .
the generic teamwork skills that underpin effective performance are similar , and the process of team training should draw on similar methods and techniques .
however , it can be seen that there are many differences between aviation and the icu in the nature of work and team performance ( table 3 ) .
it is not sufficient or desirable to simply transfer to the icu the programs developed for aviation or the operating theatre ( where , it can be argued , the cognitive structure of work is quite similar to that of aviation ) .
rather , team training in the icu must consider the ebb and flow of work in critical care , and programs must focus on routine and non - routine events , and be reflective of cognitive tasks , team structures , and group norms .
the specific team skills and behaviors that underpin team performance must be captured and explicitly stated if we are to develop a relevant and sustainable model of team training and assessment for the icu .
this article is part of a series on healthcare delivery , edited by dr andre amaral and dr gordon rubenfeld .
 the aviation industry has made significant progress in identifying the skills and behaviors that result in effective teamwork . 
 its conceptualization of teamwork , development of training programs , and design of assessment tools are highly relevant to the intensive care unit ( icu ) . 
 team skills are important for maintaining safety in both domains , as multidisciplinary teams must work effectively under highly complex , stressful , and uncertain conditions . 
 however , there are substantial differences in the nature of work and structure of teams in the icu in comparison with those in aviation . 
 while intensive care medicine may wish to use the advances made by the aviation industry for conceptualizing team skills and implementing team training programs , interventions must be tailored to the highly specific demands of the icu . 
Introduction
The aviation teamwork model
Comparisons between aviation and the intensive care unit
Conclusions
Note
Abbreviations
Competing interests