Safer Surgery 204 or the patient’s condition. Specically, on the individual level, relevant factors include technical competence, heterogeneous knowledge (Rosen et al. 2008), high work commitment (Nyssen et al. 2003) and a variety of attitudes towards the interpersonal aspect of one’s work and the effects of stress on performance (Flin et al. 2003). On the team level, anaesthetic teams are mostly crew-like (Arrow et al. 2000, Tschan et al. 2006) – structured with traditional hierarchies, varying size, sometimes no previous experience as a team and almost no formal training in teamwork or interaction with one another. Finally, the context of anaesthetic teamwork usually includes highly structured organizations and the necessity to be attentive to a range of tasks (Leedal and Smith 2007). Tasks are characterized by routine procedures as well as by rapidly shifting priorities, requiring the handling of high risks where failures can potentially endanger human life. Thus, as suggested by functional models of teamwork (Hackman and Morris 1975, Marks et al. 2001, Wittenbaum et al. 2004), team and task variants inuence clinical team performance via the interaction of the anaesthetic team members. Hence, this interaction requires coordination in order to realize effective clinical team performance (Dickinson and McIntyre 1997, Tschan et al. 2006). Besides individual medical skills, experience and patient factors, coordination within the team is a crucial factor inuencing the quality and timeliness of a reaction to unexpected complications. This coordination requirement can actually be exacerbated by the crew structure (e.g., MacMillan et al. 2004). In other words, without appropriate coordination and effective communication beyond hierarchical constraints, the team interaction could cause process losses which in turn would negatively impact team performance (Marks et al. 2002, Steiner 1972). The following section outlines mechanisms of anaesthesia team coordination. Adaptive Coordination in Anaesthesia Teams Coordination Requirements in Anaesthesia Teams Performing joint actions requires coordination in the sense of orchestrating the ‘sequence and the timing of interdependent actions’ (Marks et al. 2001, p. 363). However, it is not only the coordination of actions but also the coordination of information (e.g., sharing information regarding a patient’s allergy and discussing its implication for medication) that is important for clinical performance (Arrow et al. 2000). For example, failure to appropriately communicate relevant information (e.g., patient allergies) to all team members is a frequently reported incident in anaesthesia (Catchpole et al. 2008) and problems in information transfer are generally well known in the domain of healthcare (Cook et al. 2000, Murff and Bates 2001). This might be due to the fact that in medicine, task-relevant information is often unshared and has to be obtained either from the patient, other team members, written notes or from several monitors in the operating room. Measuring Coordination Behaviour in Anaesthesia Teams 205 These complex information requirements (Hirokawa 1990) pose high demands on team coordination. After having dened what has to be coordinated during team interaction, questions arise on when – during interaction – specic coordination is appropriate. As stated above, anaesthesia is characterized by routine as well as by non-routine procedures in the sense of rapidly shifting priorities. In non-routine situations, teams have to manage unexpected and unfamiliar problems potentially endangering the system or outcome (Waller et al. 2004). This is a signicant point as a non- routine event (NRE) in anaesthesia is by the denition of Weinger and Slagle (2002, p. S59) ‘any event that is perceived by care providers or skilled observers to be unusual, out-of-the-ordinary, or atypical’. NREs include critical incidents as well as a broad range of events that might not lead to immediate adverse outcomes but nevertheless could be early heralds of post-operative patient outcomes (Oken et al. 2007). A recent survey in anaesthesia has shown that NREs occur in 30.4 per cent of reported cases (Oken et al. 2007). By their very nature, NREs are likely to be ill-dened problems resulting from ambiguous cues and therefore requiring diagnostic effort to dene the problem. Interestingly, studies from a comparable domain, aviation, showed that non-routine situations require more communication than routine situations (e.g., Orasanu 1993). The question arises as to how these results can be transferred to anaesthesia and how anaesthetic teams can coordinate actions and information adaptively to routine and non-routine situations. Adaptive Coordination Team adaptation means a change in team performance in response to a salient cue leading to a functional outcome for the entire team (Burke et al. 2006). For example, teams perform better when their members adapt their role behaviour in response to unanticipated change (LePine 2003) or when they change leadership behaviour depending upon the level of routine of a situation, the degree of standardization or experience of team members (Künzle et al. in press). As Manser and co-authors (2008) pointed out, adaptive coordination occurs on different organizational levels. Adaptability has been found to be fundamental to establishing safety (Salas et al. 2007b) and has been examined as one of the core components of effective teamwork and a prerequisite for coordination (Salas et al. 2005). In our work, we focused on adaptive coordination on the team level and argue that adaptability can be considered a coordination process in and of itself rather than simply a prerequisite to coordination. Similar to contingency models of leadership (e.g., Fiedler 1964), the concept of adaptive coordination implies that different coordination mechanisms are appropriate in different situations. The core idea of adaptive coordination lies in the dynamic use of coordination mechanisms in accordance with the workload of a given situation (Entin and Serfaty 1999, Grote et al. 2004, Rico et al. 2008, Salas et al. 2007a, Serfaty and Kleinman 1990). Here, workload describes a relationship between available resources such as information processing capacity and task demands (Byrne et al. 1998, Young et al. 2008) and Safer Surgery 206 refers to how a given situation is perceived by the person facing the task (Grote et al. 2003). However, it is not only the coordination behaviour in either routine or non-routine situations which is linked to team performance. Rather, it is the adaptive transition from routine to non-routine and vice versa which seems to have signicant effects on team performance (Waller et al. 2004). The question then arises of how coordination should be changed in the adaptive transitions and by which behavioural means it can be executed. Means of Adaptive Coordination Within the literature on team coordination, scholars have differentiated between explicit and implicit coordination mechanisms (Entin and Serfaty 1999, Espinosa et al. 2004, Kolbe and Boos 2009, Grote et al. 2003, Wittenbaum et al. 1998, Zala- Mezö et al. 2009). Explicit coordination is behaviour that is intentionally used for the purpose of team coordination and mostly executed by means of verbal or written communication (Espinosa et al. 2004, MacMillan et al. 2004, Wittenbaum et al. 1998) or by transferring information and resources upon request (Serfaty and Kleinman 1990) and can be used prior to or during team interaction (Wittenbaum et al. 1998). In medicine as well as in other high reliability contexts, a typical form of explicit pre-coordination is standardization of behaviour through rules (Grote et al. 2004). During the interaction, the team process can be explicitly coordinated by mechanisms such as commands or afrmations (Marsch et al. 2004). It was found that healthcare teams which successfully treated a cardiac arrest showed more explicit coordination than poorly performing teams (Marsch et al. 2004). Explicit coordination can also be used to support group decision processes, for instance by repeating task-relevant information (Kolbe 2007). Explicit coordination is clear and generally understandable but involves communicative effort and time. It can be executed by every team member on every hierarchical level or in the sense of shared leadership. Implicit coordination is postulated to be primarily based on shared cognition and on the anticipations of the actions and needs of the team members (MacMillan et al. 2004, Rico et al. 2008, Serfaty and Kleinman 1990, Toups and Kerne 2007, Wittenbaum et al. 1996) and is also related to team situation awareness (Manser et al. 2008, Salas et al. 2005). In a recent study of anaesthesia teams, it was found that transactive memory (knowing who knows what) predicted team members’ perceptions of team effectiveness, and also affective outcomes such as team identication and job satisfaction (Michinov et al. 2008). Compared to explicit coordination, implicit coordination is less time intensive, but is only effective if the team members have not only shared but accurate mental models of the task and the team interaction. If one of these two • • Measuring Coordination Behaviour in Anaesthesia Teams 207 requirements is not met, reliance on implicit coordination can be very risky. This is in line with the proposals by Wittenbaum et al. (1998) who postulated that implicit coordination can be ineffective in complex and interdependent tasks. They suggested that the more coordination required (e.g., divergent goals, unequal information distribution, ambiguity of opinions and preferences), the more group members need to coordinate explicitly. In fact, explicit coordination has been considered to be a prerequisite of implicit coordination (Orasanu 1993). Given the fact that both implicit and explicit team coordination modes have advantages and disadvantages, the suggestion is that they be used according to the situational demands (Grote et al. 2004). However, in medical teams there seems to be an inherent preference for implicitness as the silver bullet of coordination styles and reluctance against being explicit. As Heath and colleagues (2002) observed in operating theatres, team members would rather unobtrusively encourage others to perform certain actions with the underlying assumption that explicitly asking them for assistance or consideration was inappropriate or would interrupt activities in which they were already engaged. This tacit assumption that ‘the more implicit the communication, the more effective it is’ could be problematic in non- routine situations where explicit coordination is required (Wittenbaum et al. 1998). To ensure that such needs for explicitness are identied, it seems that heedful interrelating can be a useful mechanism of adaptive team coordination. The idea of heedful interrelating was introduced by Weick and Roberts (1993) and has received considerable attention. It includes certain attitudes and behaviours towards the team and the situation in order to act in close alignment with situational and team requirements. Being a heedful team member implies being mindful of the team goal and one’s own contribution to it (Dougherty and Takacs 2004). This means that while being heedful, the team members constantly reconsider their own contributions in relation to the team goals (Grommes and Grote 2001, Weick and Roberts 1993). It also means that rather than acting only habitually, team members act purposefully with regard to the joint situation (Dougherty and Takacs 2004) and are well aware of how their actions t into the overall team goal (Wears and Sutcliff 2003). This form of mindfulness is especially relevant for complex and tightly coupled systems (Vogus and Welbourne 2003). Recent research results have shown that heedful interrelating mediates the relationships of trust in team members and monitoring by team members with future team performance (Bijlsma- Frankema et al. 2008). Heedful interrelating consists of three different actions: (1) the individual contribution by providing own actions, (2) the representation of the system of joint actions and (3) the nal interrelation or subordination of own actions within the envisaged system (Dougherty and Takacs 2004, Grommes and Grote 2001, Weick and Roberts 1993). Thus, heedful interrelating is related to the anticipation of the needs of other team members but can be regarded as a Safer Surgery 208 coordination mechanism that goes beyond mere implicit coordination because it can allow team members to identify needs for explicit coordination (Grommes and Grote 2001). For instance, one team member might realize that his or her own or someone else’s actions are not in line with the team goal and therefore the work process has to be reorganized. Heedful interrelating also extends team orientation (see Salas et al. 2005), because the latter is conned to an attitudinal preference for working with others and enhancing individual performance while working with others. Furthermore, heedful interrelating can prevent team members from narrowly following protocols or from over-learned responses (Wears and Sutcliff 2003) and might allow team members the exibility to speak up when necessary which in turn enhances learning and adaptability (Edmondson 2003), as well as the overall effectiveness of the team. Still, some authors argue that heedful interrelating refers to a way in which behaviour is enacted rather than to the behaviour itself (Druskat and Pescosolido 2002). In line with this, only a few studies have analysed concrete behaviours or communication by which heedful interrelating could be enacted (Cooren 2004, Grommes and Grote 2001, Grote et al. 2003, Zala-Mezö et al. 2009). A recent study on coordination in anaesthesia teams showed that heedful interrelating occurred more in situations of high workload than in low workload phases (Zala- Mezö et al. 2009). Thus, we need to know more about the interplay of explicit and implicit coordination and how heedful interrelating facilitates the adaptive transitions between these coordination modes. Measuring Adaptive Team Coordination Behaviour in Anaesthesia The objective of our current research on anaesthetic team coordination is to gain a broad perspective of anaesthetic team behaviour coordination during routine and non-routine and relate it to clinical performance. This requires detailed analyses of team processes which have proven to be costly in both time and effort. However, some authors suggest that not doing these analyses would be even more costly because one would then be forced to forego key information regarding comparative team dynamics and adaptation behaviours (McGrath and Altermatt 2002). As Weingart (1997) concluded, gaining knowledge regarding what anaesthetic teams actually do, how they complete their work and the resulting levels of success increased our understanding of which processes (in this case, coordination) inuence group performance, specically clinical effectiveness. However, measuring explicit and implicit team coordination as well as heedful interrelating is far from being a straightforward endeavour that allows us to draw on a variety of existing methods. Even though implicit team coordination has been analysed experimentally (Wittenbaum et al. 1996) and by using self-report measures (Rico et al. 2008), studies on behaviour observations of implicit coordination are rare (Entin and Serfaty 1999, Grote et al. 2003, Kolbe 2007, Serfaty et al. 1993, Zala- Mezö et al. 2009), a fact that might be due to the tacit nature of implicitness. Measuring Coordination Behaviour in Anaesthesia Teams 209 Thus, the necessity to investigate effective and adaptive team coordination and the lack of suitable observation methods led us to develop a taxonomy of explicit and implicit team coordination and heedful interrelating behaviour. Taxonomy of Explicit and Implicit Team Coordination and Heedful Interrelating Behaviour The taxonomy we developed for our research on adaptive coordination in anaesthesia teams consists of three main categories: explicit and implicit coordination, heedful interrelating and other behaviour (Figure 13.1). The main category of explicit and implicit coordination includes two sub-categories: coordination of information exchange and coordination of actions (Arrow et al. 2000). Within these sub- categories we differentiate explicit from implicit coordination mechanism, as shown in Figure 13.1. The applied taxonomy was developed to measure coordination mechanisms with regard to explicitness, implicitness and heedfulness. Its strength lies in the precise yet practical description of behaviour patterns specically found in anaesthesia teams. The subcategories were developed in an iterative process based on previous work (Grote and Zala-Mezö 2004, Grote et al. 2003, Grote et al. 2004), on team coordination literature (Arrow et al. 2000, Bowers et al. 1998, Espinosa et al. 2004, Kolbe 2007, Marks and Panzer 2004, Marsch et al. 2004, Rico et al. 2008, Salas et al. 2005, Serfaty et al. 1993, Serfaty and Kleinman 1990, Toups and Kerne 2007, Tschan et al. 2006, Wittenbaum et al. 1996, Wittenbaum et al. 1998), and on literature regarding heedful interrelating and related concepts (e.g., Bijlsma- Frankema et al. 2008, Dougherty and Takacs 2004, Druskat and Pescosolido 2002, Grommes and Grote 2001, Rhee 2006, Toups and Kerne 2007, Vogus and Welbourne 2003, Weick and Roberts 1993). Table 13.1 gives denitions and examples of these coordination mode categories. Data were coded using INTERACT (Mangold 2007), a coding software which allows for marking and coding events within a digitalized video without the need for transcribing the communication. In order to analyse the dynamic coordination process and determine whether a certain coordination act is followed by another coordination act and how long each act lasts, focal sampling (observing the whole group for a specied amount of time such as the induction to anaesthesia) and continuous coding are required (Bakeman 2000, Bakeman and Gottman 1986, Martin and Bateson 1993). However, in doing so, the procedure of (1) dening coding units (amount of behaviour that is assigned to one category) and (2) coding these units into categories were confounded because the coding units are dened with reference to the categories (McGrath and Altermatt 2002), a practice which usually impairs the reliability of an observation method (Kolbe 2007). But, since there were no appropriate unitizing rules for verbal and non-verbal interaction, we had to dene the coding units as utterances or actions by a team member that t into a single category. Safer Surgery 210 Figure 13.1 A taxonomy of explicit and implicit team coordination and heedful interrelating behaviour Note: Coding units are here dened as utterances or actions by team members that t into one category (Bales 1950, Beck and Fisch 2000, Marby and Attridge 1990). For each act, the actor, the target, and the duration are coded. Behaviour of the anaesthetic team member Explicit & implicit coordination Heedful Interrelating A ttention focus on the joint situation Com- prehension of implications of unfolding events Providing unsolicited task-relevant action Offers of assistance Indications of satisfaction with fulfilment of task Monitoring Declaring own needs A ssistance requests Approval Planning and procedural q uestions Verification questions Questioning decision Providing actions upon request In-process decisions Initiating actions Making plans A ssigning tasks Giving orders Coordination of actions Provide unsolicited task-relevant information Obtaining unsolicited task-relevant information Listening Requests for information Providing information upon request Verifying information A cknowledge- ment Summary Questioning information Explicit Implicit Explicit Implicit A uthoritarian behaviour Silence and action Silence and no action Chatting Technical alarm Talking to patient Broad boundaries o f envisaged system Focusing on representation of others Watching the actions of other team members Verbalising own behaviour Verbalising interpretation of a situation Correcting behaviour of other team members Considering others Teaching others Giving feedback in a positive manner Giving feedback in a negative manner Considering the future Considering external conditions Note making Incom- prehensible communication Others Coordination of information exchange Measuring Coordination Behaviour in Anaesthesia Teams 211 Category Definition Example Explicit coordination of information exchange Requests for information Checklist questions asked of team members or questions addressed to the patient. ‘Where’s the debrillator?’ ‘Do you have any allergies?’ Providing information upon request Includes answering direct questions. I nformation is given only in response to direct questions. ‘The debrillator is right behind you.’ Verifying information Includes repeating information or giving verbal conrmations regarding fullled actions. ‘Electrodes are checked.’ Acknowledgements Includes verbal statements indicating one has heard or understood given information. ‘Okay .’ ‘ Um hm.’ Summary Includes statements regarding state of affairs or processes. ‘W e had an asystole in reaction to laryngoscopy. We treated it with atropine and 30 seconds of heart massage.’ Questioning information I ncludes statements expressing doubts about the accuracy or source of information. ‘Are you sure he has no aller gies?’ Note making Coded when a team member lls out the patient’s chart. Implicit coordination of information exchange Pr oviding unsolicited task-relevant information Providing information without being asked to do so. ‘Blood pressure is okay.’ Obtaining unsolicited task-relevant information Includes actively garnering information without being asked to do so. Reading patient’ s chart. Listening Includes obviously and attentively listening to another team member or patient with undivided attention. Explicit coordination of actions Assistance requests Include explicitly asking for help. ‘Can you help me with this?’ Table 13.1 Denitions and examples for categories Safer Surgery 212 Category Definition Example Giving orders Include directives, commands, or instructions. ‘Can you hold this?’ ‘Give him the fentanyl.’ Assigning tasks Coded when subtasks are assigned to team members. ‘I’ll intubate, you watch the monitor .’ Making plans Include verbalizations of non-immediate considerations regarding what should be done and when. ‘When we’ve nished intubation we’ll call for an OR nurse.’ Initiating actions Include statements or behaviours which initiate actions (not orders or decisions). ‘We could give him more fentanyl.’ In-pr ocess decisions I nclude statements of decision such as dening timing of intubation initiation. ‘We can intubate now .’ Providing actions upon request I ncludes behaviour that is performed because asked to do so. After the physician has asked the nurse to administer the fentanyl, the nurse accepts the order and administers the drug. Questioning decisions Occurs when somebody expresses doubts concerning a decision, order or proposal. ‘ A re you sure you want to intubate right now?’ V erication questions Include somebody asking a question to make sure they are about to do the right thing. ‘I’ll start now , is that alright?’ ‘You’ve already administered the atropine, right?’ Planning and procedural questions I nclude questions concerning procedure and further courses of action. ‘How much fentanyl do you want me to give?’ Appr oval Includes short verbalizations of acceptance in reaction to a proposal. ‘Good idea.’ Implicit coordination of actions Pr oviding unsolicited task-relevant actions Include task-relevant actions completed without being asked to do so. After the physician announces he/she is going to intubate, the nurse holds out the laryngoscope. Table 13.1 Continued Measuring Coordination Behaviour in Anaesthesia Teams 213 Category Definition Example Offers of assistance Coded when somebody verbally offers help. ‘Can I help you with this?’ Indications of satisfaction with fullment of task I nclude statements of general agreements. ‘F ine.’ ‘Okay .’ ‘Good.’ Monitoring (patient or machine) Codes when a team member checks the monitor or behaviour of the patient. Reading indicators on a monitor . Declaring own needs Includes verbal statements expressing personal need for something (without asking another person for it). ‘I don’ t have gloves.’ ‘I’m so thirsty.’ Heedful interrelating Watching actions of other team members Coded when a team member observes the actions of his/her colleagues. Team member watches what another team member is doing. V erbalizing own behaviour Occurs when personal task action is verbally communicated. ‘ I’m calling the attending.’ ‘ I’m turning the alarm down.’ Verbalizing interpretation of a situation Includes declarations or assessments of a situation. ‘That was close!’ ‘Now he seems to feel better .’ Correcting behaviour of other team members I ncludes actions that correct the behaviour of a colleague. ‘No, you should plug it in here.’ Considering others Includes attention given to another’ s condition inuencing task fullment. ‘Are you okay?’ ‘Thanks.’ Teaching others Includes detailed explanations or demonstrations beyond the mere correcting of a behaviour of another team member. ‘The way you did that wasn’ t wrong but it’s easier if you do it this way.’ Giving feedback in a positive manner I ncludes friendly reassurances to a team member. ‘That was a very good reaction.’ Giving feedback in a negative manner Includes providing feedback in a less-than-sincere manner . ‘This was not too bad.’ Considering the future Includes considering the consequences of personal or other’ s actions. ‘We have to be careful with this tube because we have to put him in a prone position afterwards.’ Table 13.1 Continued . Safer Surgery 204 or the patient’s condition. Specically, on the individual level, relevant factors. information processing capacity and task demands (Byrne et al. 1998, Young et al. 2008) and Safer Surgery 206 refers to how a given situation is perceived by the person facing the task (Grote. is related to the anticipation of the needs of other team members but can be regarded as a Safer Surgery 208 coordination mechanism that goes beyond mere implicit coordination because it can