Two is a crowd

A team may, very loosely, be defined as two or more people working towards a common goal. The benefits of working in a team are manifold: shared physical and mental workload, balancing of strengths and weaknesses, error trapping, etc. More accurately, the preceding sentence should be modified to say "The benefits of working in a good team are manifold." We have all had experience of dysfunctional teams which were much less than the sum of their parts, and would probably have functioned better if the individuals had worked independently. As Reason and Hobbs state: "Team management errors are one of the most serious threats to safety... problems include":

• team leaders being over-preoccupied with minor technical problems
• failure to delegate tasks and responsibilities
• failure to set priorities
• inadequate monitoring and supervision
• failures in communication
• failure to detect and/or challenge non-compliance with SOPs
• excessively authoritarian leadership styles
• junior members of the crew or team being unwilling to correct the errors of their seniors

Although much depends on effective team members, the above list suggests that good leadership is paramount. Ironically, the education system from primary school on to postgraduate education praises and rewards individual excellence. This means that the A+ students who have become excellent personal achievers are then expected to work in, and lead, teams with very little prior preparation for this role. Although courses, such as Advanced Life Support (ALS), expect candidates to show leadership skills, the team members are often faculty members and have to be spoon-fed instructions. Ostensibly this allows candidates to be assessed on their skills, without variable support from the team, but it creates unrealistic scenarios.

It is perhaps not surprising for the director of a simulation centre to suggest that simulation is part of the solution to team training. However, this is one of the greatest benefits of inter-professional simulation, whether in situ or in the simulation centre. Repeated practice with a focused debrief allows, some might say forces, teams to become more effective. There is still too much expectation within healthcare that competent individuals, when placed in the same room, will work well together. Unfortunately this is not the case. And practicing on an ad hoc basis with real patients is not only unethical but also ineffective; the lack of time for a debrief and the lack of uninvolved observers makes learning from real patients difficult. So, could your team could be practicing working together in a simulation centre (or in situ)? And if your team isn't doing this then how do you justify poor performance in real cases?