Building Trusting Health Care Teams

The United States Navy Sea, Air, and Land (SEAL) Teams, commonly known as the Navy SEALs, are widely recognized as one of the highest-performing groups in the world.1 Yet when it comes to choosing new members, it is not performance that is emphasized. In fact, those chosen for the Navy SEALs are not necessarily the highest-performing candidates. The SEALs have learned that it is trust that matters more than performance. Candidates with low performance and high trust are thus preferred over those deemed to be high performers with low trust. High performers with low trust are actually thought to be toxic team members. So, while knowledge and skill are certainly important, humility and personal accountability are even more highly desired. While shooting skills, orienteering, and battlefield aptitude are considered, the deciding factor in choosing future SEALs is more likely to be respect, teamwork, and integrity off the battlefield.1 This focus on building trusting teams is shared by other branches of the United States military. Army Sergeant Major Daniel Dailey, for example, states that “arguably, the highest performing squads in our formation are those that are built upon trust.”2 Furthermore, Air Force Colonel John Langell argues that “trust is the bedrock upon which the Air Force functions.”3 The trust-building approach of the Navy SEALs and other military branches similarly applies to health care teams, especially in high-stress fields like anesthesiology or critical care. The American Hospital Association acknowledges the role of trust in health care teams and the value of mutual support in reducing medical error and enhancing patient safety.4 This focus on building trusting teams is also seen in aviation,5 intensive care,6 surgical,7 and emergency response8 settings. In this commentary, we discuss medical-political hyperpolarization among health care professionals in the United States (Figure 1). We address the formation of echo chambers, and the threat that this can pose to both provider experience and patient safety in health care. We delve into building trusting teams as 1 pillar of practicing the infinite game in health care. We further explore paths forward that facilitate finding common ground and building a culture of collaborative conflict (Figure 2). Lastly, we present the details of a real-world example of fostering a collaborative conflict culture in an anesthesia care team through the implementation of an immersive retreat for interprofessional teams entitled the High Performing Care Collaborative (Figure 3).Figure 1.: Current state of affairs in anesthesiology care in the United States.Figure 2.: Collaborative conflict culture: normative behaviors and favorable results.Figure 3.: Salient elements of the University of Alabama at Birmingham (UAB) Anesthesia Care Team Optimization Committee (ACTOC) and High Performing Care Collaborative (HPCC).9 , 10CURRENT STATE OF AFFAIRS A recent article encouraged anesthesiologists and nurse anesthetists to move beyond narratives that frame the groups as entrenched political rivals.11 But over the past several decades, in professional politics in the United States, trust has not been the norm between many physician groups and their respective advanced practice provider (APP) colleagues. After existing for 53 years as the American Academy of Physician Assistants (AAPA), the AAPA celebrated a 2021 Utah law allowing physician assistants (PA) to practice without the supervision of a physician, by changing its name to the American Academy of Physician Associates.12 Nurse practitioners (DNP), pharmacists (PharmD), audiologists (AuD), physical therapists (DPT), and occupational therapists (OTD) have all seen their training programs transition to doctoral degrees. Legal debates at the state level have sought to clarify the question: “Who is a doctor?” Georgia recently passed a state law banning “medical title misappropriation” and prohibiting nonphysicians from using the title “doctor” in clinical settings. The Georgia “Health care Practitioners Truth and Transparency Act” further requires advanced practice nurses and physician assistants with doctorates to specify in their advertising that they are not medical doctors.13 In the perioperative arena, use of the term “anesthesiology” has entered the battlefield, with the American Association of Nurse Anesthetists changing its name to the American Association of Nurse Anesthesiology (AANA) and converting its training programs from master’s degrees to doctorates.14 The American Society of Anesthesiologists (ASA) has condemned this move as being deceptive and dangerous for patients.15 For health care teams often called to care for the sickest surgical patients in the most acute settings (Figure 1), this is a far cry from the trust that the Navy SEALS demand of their teams and teammates. Social Media and Echo Chambers Further evidence of escalating polarization among health care providers can be found on professional message boards and social media platforms, where numerous disrespectful and toxic exchanges occur between physicians and APPs. The social media ecosystem often intensifies group-based emotions—and identification—while simultaneously heightening our attention to highly emotional content. Though social media can be used for good, there are many instances where it serves as a platform and catalyst for toxic discourse. All of this happens within an echo chamber of fervent beliefs, with the potential to become a rapidly spreading firestorm.16 An “echo chamber” is defined as “a self-reinforcing mechanism that moves the entire group toward more extreme positions.”17 It occurs when individuals are continuously exposed to beliefs and opinions like their own.18 Under these conditions, groups are more prone to the common psychological phenomenon of group polarization, which highlights the “accentuation of individual proclivity after group deliberations.”19 Unfortunately, social media has been found to be a key promoter of polarization,20 with the potential to catalyze extreme positioning—often leading to radicalization.21 One study refers to these situations as “throwing individuals into the midst of a political war, forcing them to pick sides, and thus transforming the social identities into the substance of intergroup conflict.”22 Not unexpectedly, surveys on incivility in health care reveal that 70% of physician executives believe that disruptive behavior occurs at least once a month in their hospitals,23 while 67% of doctors and nurses tie disruptive behavior to medical error.24 Thus when professional politics cause open conflict and resentment between physicians and APPs, there should be concern about the adverse implications for the professional well-being and fulfillment of care teams and their patient care. A recent article in the anesthesia literature described how these political conflicts can spill over into the operating room, at the point of patient care, in the form of microaggressions, stereotyping, and role ambiguity, all of which can threaten patient safety and promote health care professional burnout.25 Research shows that workplace dignity is correlated with increased organizational commitment and decreased turnover intentions.9 However, the widespread dissension and rivalry-related issues point to a less-than-dignified environment, and the ramifications of this are evident. Recent physician data demonstrate that approximately one-third of physicians are at risk for leaving their current institutions because of burnout and lack of professional fulfillment.10 Moreover, there is mounting evidence detailing the state of burnout across health care professionals.26 As social media becomes ever present in daily life, and as its polarization effect spreads beyond the confines of cellphone and computer screens and into health care workspaces, we must ask: How can we deliberately move away from polarizing echo chambers that can drive division and ill-being and instead toward more fruitful, sustainable, and trusting discussions? TRUST IN HEALTH CARE TEAMS It was recently suggested that anesthesia professionals should approach the future of perioperative care with an infinite mindset.11 While one could argue that health care teams were trusting before the push for APP autonomy, the “infinite game” approach would be to follow a purpose-driven strategy and path rather than responding to a competitor’s antagonistic approach.11 In The Infinite Game, Simon Sinek proposes 5 pillars of leading with an infinite mindset: (1) advancing a just cause, (2) building trusting teams, (3) studying worthy rivals, (4) preparing for existential flexibility, and (5) demonstrating the courage to lead.1 Here we will delve into 1 of these pillars: building trusting teams. While one would hope that the topic of trust in health care teams had not only an agreed-on definition but also validated metrics to measure and study, this is unfortunately not the case. In the organizational management literature, there are ample studies on definitions, metrics, and performance measures for trust. A recent scoping review of the health care literature, to the contrary, revealed no consensus on the most appropriate definition for trust within health care teams. Given that most of the studied models are unique to individual institutions and many are not validated, it was recommended that “further empirical research is needed…to fully explain trust in health care teams.”27 Fortunately, a recent study on faultlines in hospital teams shined a light on building trust within health care teams.28 Faultlines occur when multiple attributes of hospital team members align, dividing the team into homogeneous subgroups—not unlike the hyperpolarization seen in echo chambers on social media platforms and message boards, as described above. This homogeneity, when not properly managed, can lead to decreased civility among teams, which was found to be directly associated with increased medical error and patient mortality. Of note, a 10% increase in unit incivility was linked to a maximum 10.6% increase in patient mortality.28 Interestingly, a collaborative conflict culture was found to mitigate the direct relationship between faultlines and incivility, potentially mitigating the negative impact on patient outcomes.28 We propose that such published work on collaborative conflict aligns with the goals of enhancing patient safety and experience, enhancing clinician experience and wellbeing, and fostering trust in health care teams. Collaborative Conflict Culture A collaborative conflict culture is one in which employees are empowered to manage conflicts actively and cooperatively, to best serve the interests of the larger group (Figure 2). Values of a collaborative conflict culture include “active listening to the opinions of others, mediation of different perspectives, open discussion of the conflict, and demonstrations of mutual respect.”28 In this culture, the standard response to conflict is to seek the best solution possible for all parties involved in a prosocial and cooperative way. Underlying values of mutual respect, active listening, and openness to differing opinions can serve as a “social glue” whereby distinct and sometimes opposing subgroups can manage their differences collaboratively and inclusively. Under these conditions, conflict can be constructive and can help alleviate the negative effects of strong faultlines and incivility.28 Interestingly, health care teams with stronger faultlines yet high collaborative conflict cultures were found to be more civil than teams with weak faultlines.28 Stated differently, strong faultlines—within the boundaries of an overarching culture that facilitates communication and trust—may contribute to higher functioning, greater well-being, and stronger performing teams. This aligns with research on social identity theory, which points to the formation of subgroups as not necessarily being a detriment, and perhaps even being a benefit, to group cohesion.29 Furthermore, invoking a common group identity only seems to minimize intergroup hostility when the integrity of subgroups is protected. When the larger group identity is seen as a threat to valued subgroup identities, subgroup members engage in aggressive tactics to preserve subgroup boundaries.30 Hence, keeping subgroup identities intact and protected, within the context of a broader group identity, may be the “secret sauce” to promoting intergroup civility and trust. HIGH-PERFORMING CARE COLLABORATIVE Promoting civility, collaboration, and trust in health care teams requires intentionality. It further requires bold leadership, as the time needed to nurture a collaborative conflict culture cannot simply be “added on” to a workforce already strained by overwhelming clinical demands. As such, removing health care professionals from their revenue-generating clinical roles to immerse themselves in intentional care team building is a financial decision that requires leaders willing both to invest in their people and to justify this decision to those tasked with monitoring departmental and hospital finances. The Joint Commission has repeatedly cited failures in teamwork and communication as the top causes of sentinel events,31 and research has revealed that approximately 1 in 20 patients experience preventable harm in medical care.32 Excess hospital length of stay attributable to such preventable patient harm has been estimated at over 2 million days annually, with an opportunity cost of over $9 billion—leading authors to recommend that “investments in developing and evaluating mitigation strategies for preventable patient harm are urgently needed.”32 The American Hospital Association bolsters this value proposition by stating emphatically that “an investment in the frontline has never been more important to patient safety.”33 The University of Alabama at Birmingham (UAB) High Performing Care Collaborative (HPCC) represents an example of (a) intentionality in fostering care team collaboration and trust and (b) leadership in signaling to health care professionals that culture matters (Figure 3). HPCC is an off-campus, 2-day immersive retreat designed for intact front-line care teams from across the UAB health care footprint. This collaborative with the UAB Leadership Development Office (LDO)34 was created as an extension of the prior work of the UAB Anesthesia Care Team Optimization Committee (ACTOC).35 The primary goal of the UAB ACTOC/HPCC collaboration was to scale the mission of building and promoting an inclusive, respectful, and fulfilling anesthesia care team to the front lines. Interprofessional teams consist of anesthesiologists, nurse anesthetists, perioperative nurses, and surgeons, who work together routinely but who may have never had the opportunity to forge trusting relationships. At the outset of the HPCC, all participants complete the Disk assessment tool36 to evaluate their personality and behavioral style, and participants spend the morning of day 1 reviewing not only their own assessment, but those of their teammates. Participants frequently comment that this experience is eye-opening in allowing them to better understand themselves and their teammates. The balance of day 1 of this interactive and immersive retreat is then dedicated to not only educating on interpersonal and team concepts such as conflict management, productive conflict, collective intelligence and teaming, mutual learning mindset, and change management but also facilitating a discussion among team members using these topics as a guide. The goal is not to give participants immediate solutions to the challenges they face on the front lines. It is instead to facilitate an environment where team members are comfortable sharing ideas, taking risks, and displaying vulnerability by suggesting novel ideas to known problems. Participants are encouraged to acknowledge where weaknesses in communication and trust can and will occur. day 2 is dedicated to strategic planning so that these collective ideas and solutions can be successfully implemented. Topics include time and meeting management, strategic planning models like SWOT (Strengths, Weaknesses, Opportunities, and Threats) and Strengths, Challenges, Opportunities, and Priorities (SCOP), along with discovery-driven planning. LDO and ACTOC facilitators focus less on lecturing and more on workshopping these topics with participating teams while coaching team members through challenging yet vital discussions. As such, significant time during each day is dedicated to open dialogue and discussion among team members, with HPCC leaders available as needed for facilitation and encouragement. Teams walk away with a jointly crafted strategy for their respective service lines and a new understanding and respect for all team members. HPCC facilitators then longitudinally follow-up with participants to offer assistance in meeting desired goals and clearing potential hurdles, with the goal of bringing the teams’ strategies to fruition. HPCC facilitators are also available for individual and team coaching as needed by HPCC alumni. Participants are encouraged to give feedback on their HPCC experience, and HPCC leaders iteratively incorporate participant suggestions into future workshop sessions. While this effort initially included UAB anesthesiologists, surgeons, nurse anesthetists, and perioperative nurses, future efforts will be directed at bringing in other health care professionals across the institutional footprint. The perioperative space unites health care professionals from many different backgrounds in the pursuit of outstanding patient care, yet institutions differ in care team background and composition. Having previously commented on domestic tensions between certified nurse anesthetists (CRNAs) and certified anesthesiologist assistants (CAAs),11 and on international perioperative professional political tensions,37 we acknowledge that local team compositions will vary. We offer that this work is applicable to teams of various compositions at the local institutional level. Furthermore, we believe that the need for trust in health care teams extends far beyond the operating room. HPCC is thus offered to all medical, surgical, and administrative teams in our health care system. The initial investment in HPCC was based on (1) a need to scale the ACTOC mission and vision, (2) a belief that building a trusting and supportive work environment would benefit patients and clinicians alike, and (3) published relevant experiences in the armed forces, aviation, and health care. Future justification, however, should be more granular. To that end, efforts are underway to engage qualitative researchers to explore validation methods such as phenomenology, grounded theory, and to medical research and to further the workshop In the support is based on follow-up and with HPCC teams to hurdles, clinical and The for teams tensions over of practice is thus to seek their common in outstanding care for their patients and their shared within the larger health care system. however, not necessarily that professionals must their or their respective As an example, physicians should in their and can actively support their just as can the for their physicians should not being as being and American professional health care politics not need to be a and subgroup identities, in the context of intentionality in a collaborative culture where conflicts can may even be the key to trust within patient care teams. of This was