The COVID-19 pandemic has been a disruption to health care unlike anything we have seen in recent history. In the face of adversity, critical care nurses adapted to rapidly changing conditions and daily crises. During the past year, we also have dealt with challenges in our personal lives and in the workplace, including economic hardship and polarized responses to public issues like disease mitigation, COVID-19 vaccinations, and racism. A few of the challenges we have faced in critical care included personal protective equipment shortages, lack of clear policy to guide care for a rapidly spreading infectious virus, lack of bioethics guidelines regarding end-of-life and resource management, and evolving and sometimes evidence-deficient nursing practices for meeting patient and family needs.
The COVID-19 pandemic has also led to members of the health care team who may not normally work together to collaborate on crisis management, for example, prolonged boarding of intubated COVID-19 patients in emergency departments, units repurposed as COVID-19 units, temporary COVID-19 units erected in nontraditional environments (eg, parking garages or tents), and rapid cross-training of non–intensive care unit (ICU) staff or professionals from other disciplines to work alongside experienced critical cares.1–4 The pandemic has demonstrated our willingness to tackle shared challenges; conversely, scenarios like the ones described above also can create intensely stressful situations in which full cooperation or a universal understanding of the mission can get lost in the noise of a chaotic environment. Health care providers on the frontlines have shared how teamwork has been critical to addressing the acuity and complexity in caring for patients with COVID-19 and their families.5,6 As we look forward to a world beyond the pandemic, we need to focus on actionable goals. Regaining and maintaining the healthy culture of our teams and our units require purposeful commitment and action. As a starting point, we propose incorporating key teamwork principles used by the US military, which have demonstrated success even under adverse conditions.
Developing teamwork to cultivate a positive workforce culture is not something we always think about when defining what a successful unit performs like. Culture is how we interact and think as people and leaders within an organization; a healthy culture is established through consistent and authentic behaviors that are accordant with the American Association of Critical-Care Nurses healthy work environment (HWE) standards: Skilled Communication, True Collaboration, Effective Decision-Making, Appropriate Staffing, Meaningful Recognition, and Authentic Leadership.7 Teamwork is probably the most valued construct to fostering HWEs.8,9 Teamwork must be purposeful; it must be considered and valued every day among ourselves, our patients, and their families. Thus, a framework approach to teamwork is needed for performance sustainment during crises and to establish the most optimal conditions to ensure success.
One example of how teamwork is used consistently to overcome overwhelming odds can be found in the US military. The hard-won lessons over centuries of practice have resulted in cohesive teamwork being one of the mainstays of the US military. However, although teamwork is not a new concept, it is not necessarily easy to implement. Listed here are some of the key principles of military teamwork that can be applied in our critical care practice.
Central Tenets to Critical Care Teamwork
Collaboration is an expectation of the leader. The most successful collaborative leaders are the ones who spend as much time focused on relationships as they spend on getting tasks accomplished. Effective leaders should create the perception of a transparent environment where problems or issues can be addressed to foster unit trust. Although this concept may have been strained during the early months of the pandemic, we should continue to find ways to value and foster collaborative leadership within our work environment, regardless of assigned roles. Examples of effective leadership in health care include unit practice councils, HWE working groups, and TeamSTEPPS huddles to provide a cultural framework and maintain situational awareness.9–11
Teamwork is highly valued in critical care units. Successful teamwork needs to be constantly tended to and is a continuous process. Establishing a set of priorities once without any follow-up or support will stall important strategic initiatives. Having regular meetings to establish, track, and record milestones or objectives is critical to teamwork success.
Teamwork is constantly recognized and rewarded. Motivated critical care nurses are the foundation of a unit focused on teamwork. Reward high performers when they go above and beyond. Rewards do not always mean pay raises or positional promotions. Unit, hospital, or institution recognition, as well as gift cards, can be used to reward critical care nurses and keep them motivated while making them feel personally recognized for their hard work and sacrifice. Nonmonetary rewards may include recognizing and celebrating accomplishments and milestones, such as specialty certification.
Specific Processes to Build Critical Care Teamwork
Identify and support change champions. In every critical care unit, change champions must be identified, inspired, and empowered to implement and embrace important processes. All nurses are informal leaders; if you have not already done so, we encourage you to step forward and provide leadership in a more structured way, such as becoming a change champion.
Empower change champions to form small teams with a problem-solving focus. Change champions should feel empowered to reach out to other multidisciplinary leaders and add them to the team in order to build a unit that values teamwork and cultivates a positive lasting culture of excellence. As your unit attains a culture of excellence, everyone can be transformed into a change champion.
Embrace teamwork resources. New initiatives often involve new capabilities or health care–related platforms that must be integrated into our practice. Change is difficult for many, and new efforts, even when necessary, will be met with resistance. Teamwork can be cultivated when platform support (eg, innovative software and hardware solutions) or new and innovative tools are designed to minimize inefficiencies while new workflows are developed. Many of you embraced opportunities to initiate interdisciplinary changes during the pandemic, such as developing proning teams and incorporating other licensed professionals to provide patient care that may have been considered a nursing duty in the past. Leaders and change champions should ensure all stakeholders have access to the tools they will need for successful implementation and to keep process information flowing bidirectionally.
Maintain routine meetings to review goals and progress. Goal-driven, regular meetings are critical to establishing, measuring, and adjusting goals and objectives. Precise goals and objectives must be established ahead of time for each team-building initiative. The key to making routine meetings successful is to prepare an agenda and stick to it during the meeting. Additionally, setting and enforcing a meeting duration will help keep the meeting on topic. If the only purpose for a meeting is to provide an announcement, consider using another forum such as email and meet only when required to have discussion and/or work on initiatives. Other important ways to keep meetings short and productive are to define and manage who is responsible for such tasks as who needs to attend, what the agenda should include, who will lead the meeting, and who will take minutes.
Expect a culture of nonpunitive and open communication. Critical care nurses who embrace unit leadership should remain open to new ideas and consider all feedback. These strategies will better position leaders to foster teamwork and work in a goal-oriented environment. A nonpunitive environment is key to ensuring that every team member will feel comfortable sharing information and participating. Most successful leaders learn from their mistakes.12 Leaving your ego at the door and speaking honestly will promote valuable communication that we can all learn from.
We share this team-building information with you with open hearts. Many of you may still feel overwhelmed and raw from your pandemic-related experiences. And many of you have lost family members and colleagues to COVID-19. Patient death and patients dying alone have become far too commonplace. Some teams have been left short-staffed as nurses retired ahead of schedule, moved into less stressful work environments, or took lucrative travel assignments. Critical care nursing never was and is not currently an easy profession. You make a difference every day you walk into your work environment. We hope that you will embrace the opportunity to maintain the enhanced teamwork and interdisciplinary respect you created under difficult situations. For those who are still seeking a strong team, consider working with your colleagues and leaders to become the great team that you always wanted to be.
To purchase electronic and print reprints, contact the American Association of Critical-Care Nurses, 27071 Aliso Creek Rd, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, firstname.lastname@example.org.