Changeable high-risk environment

The ECMO team work in a changeable environment with high-risk and unstable patients; consequently, team members are exposed to a high potential for error and unexpected situations. The team is small and often needs to make decisions ‘on the fly’ in a highly charged environment. The nature of their work means that the team must discuss problems as they arise and find solutions quickly to keep the patient safe. The overall safety culture influences how ECMO team members communicate with each other and address concerns collectively. The team identified that a shared understanding of the high-pressured nature of the situation and the recognition that complications often arise could support a positive culture that avoided blame. This was vital for enabling them to speak up quickly when concerns arose and work together to identify solutions rapidly. Openness and honesty were seen as being respected and valued in this team, as a doctor pointed out:

I think we know that it’s a high-pressured situation. I think complications are common. … I think actually the team works well together, in terms of being open and honest, but also non-judgmental in their assessments… I don’t think there are there’s blame and judgment. I don’t think that’s the culture that’s developed in that team.

Clarity of processes, tasks and roles

The specialist nature of the ECMO team’s work means that participants have received extensive supervised training before they can work independently. The work they do has order and structure, in terms of the tasks that have to be safely achieved to transfer a patient. Participants described having a shared understanding of how the work is done, with the processes, tasks and roles during an ECMO retrieval being clearly defined and standardised. This clarity about the nature and order of the work to be done helped team members identify when deviations occur from the ‘usual’ course of action. Issues that arose from unexpected or unplanned events were more easily identified as voiceable concerns.21

I think everything’s like, very nicely planned. And because we’re very routined with what we do, it’s very easy to notice if there’s going to be a problem in delivering the service to the patient along the way. (Nurse)

Structured opportunities for teams to reflect together

The ordered work of the ECMO team includes structured opportunities for the team to come together during and after the cannulation and transfer—time outs, checklists and debriefs. These parts of the retrieval routine were seen as valued moments where the team came together. These opportunities supported psychological safety by providing recognised and legitimate opportunities to speak up and discuss the challenges as the work unfolded as a perfusionist explains:

I think… that set debrief, whether you do that after an ECMO [cannulation] […] maybe somebody that ordinarily wouldn’t say something that’s giving them that moment.

Participants also felt that formal departmental meetings that fed into clinical governance provided opportunities to discuss concerns and helped the team to reflect, learn and improve the quality of their service delivery:

There are, I think fora, in which we can discuss this in an open fashion. And I think that is something that also helps the team debrief. And I think we would all hope we would all be open and honest about our…if something went wrong, why it went wrong, and to take responsibility for it, and also to take responsibility for it not happening again, as much as possible mitigating risks around that. (Doctor)

Participants expressed the desire to have more opportunities, away from the retrieval itself, to discuss the challenges of the work with the wider team, as a nurse explained:

I think if we have meetings, you know, regular meetings, then we can discuss our own issues in a team […] And we can bring up our issues, they can bring up their issues […] So, yeah, regular meetings will be very helpful.

Team familiarity

A typical retrieval team comprises a consultant, a specialised nurse and a perfusionist. As such, ECMO teams comprised small numbers of people from different professional groups working closely together with specific roles. Although retrieval teams are formed and dissolved on a shift-by-shift basis, with time, team members get to know each other well and become familiar with each other at a personal level. This continuity over time, along with small talk in the ambulance or during periods of inactivity, was seen as promoting familiarity among team members.

It’s almost like a strange sort of intimacy, which sounds quite strange, but you go for long journeys in small spaces, for a lot of it, you'll be chatting or like, you know, waiting and things like that. And I think it leads to conversations […] I think that is that kind of like camaraderie that comes with going far away […] there’s an opportunity to kind of get to know people in a different way. (Perfusionist)

Social conversations made team members comfortable with each other at a personal rather than a professional level, helping to facilitate conversations across professional boundaries. Also, when factors like tiredness or stress affected communication at work, team members were more likely to forgive these mishaps. This meant that staff felt safe to be their authentic selves at work and felt supported by their team members. A nurse explained that familiarity allowed:

a background understanding of why they react in a way, but even if it’s in a way, it’s not predictable, you might have an understanding of that, they’ve been working a lot of shifts, and they’re very tired. So the reaction is a tired, kind of more cranky response than you would normally get if this is a person who’s well rested.

In summary, familiarity within the team helped flatten the hierarchy among members and promoted understanding and acceptance of each other challenges at work. Furthermore, familiarity helped team members monitor each other’s mental health and pick up frustrations and dissatisfaction early to prevent conflicts.

Task and role interdependence

Once ECMO retrieval teams arrive to take care of a patient, the responsibility for that patient gradually transfers from the hospital team to the retrieval team. Hospital teams show variable engagement with the ECMO team, and occasionally, they may disengage early, leaving this transition to be managed by the ECMO team. ECMO team members each bring distinct skills needed in the handover and transfer process to keep the patient safe. Participants recognised this interdependence. They acknowledged that they had a shared goal of keeping the patient safe during cannulation and transfer and were highly reliant on each other’s skills and support to keep the patient safe. Given the team’s small size, help-seeking behaviours occurred between different professions and tended to cross the boundaries of each role. Helping each other across the different professions was valued within the team, rooted in a climate of respect and justified by getting the work done. Participants described how team members would ask for and offer help by understanding and anticipating each other’s skills, challenges and needs. As a perfusionist explained:

Teamwork is like looking at having your specific roles, but also being aware of, especially on retrievals, when you're that unit, being aware of what other people have to do, and helping them with it. So sometimes, maybe crossing over to do something that isn't technically your job, but that needs doing […] I think that is good teamwork because you're very aware of what everyone else in your team is doing.

However, this necessary flexibility in role and task came with a potentially blurred understanding of ‘who should do what’. This could threaten team members’ sense of psychological safety, grounded in an understanding of the scope of their role and their ability to perform this role optimally to keep the patient safe.

I think there’s a bit of confusion between the role of the perfusionist and the retrieval nurses sometimes. I know, when we go out with like [a perfusionist] likes to scrub. And I like to scrub because I feel like that’s my main role. And I have to be specialist with my role. (Nurse)

Hierarchy and domains of expertise

Hierarchy is traditionally considered a barrier to speaking up,22–24 and ECMO team members were aware of hierarchical differences among its members. However, in this team, the confidence to speak up was not affected by the institutional role but by their domain of knowledge and the remit of their professional role.

I do a technical thing, I run a machine… if someone says what cannulas should we use, what equipment should we use? That’s, I’m trying to do that. I know I have that knowledge. And I’m very happy to make a very firm decision about it. (Perfusionist)

Individuals were confident to raise concerns that fell within their domain of expertise but less so in raising a concern that fell within the domain of expertise, skill set or scope of practice of a different professional role with different skill set, scope of practice, due to the anxiety about uncovering a knowledge gap.

If I had to speak up to a nurse, and they were doing something like drawing drugs, or doing a dose calculating, or whatever, that I don’t do very often …if I noticed something with a nurse or drug, I was like, Oh, I’m not sure about that. I do. I double-guess myself more before speaking up. Because I don’t know. (Perfusionist)

Decisions around ECMO candidacy are mainly made by medical professionals. Nurses did not feel comfortable challenging these decisions despite having an opinion. However, rather than being a reflection of reticence to challenge a more senior member of the team, they described their reluctance as arising from an awareness of the boundaries of their role and a lack of knowledge and training to question these decisions.

I feel I should not distract when doctors are discussing serious cases, because in the end of the day, they make decision who is suitable for ECMO […] [Some] things are not able to discuss because of my skill levels. Not because I’m not comfortable to discuss […but] I don’t feel is [my] role. […] We do different jobs. […] I need to respect that level and that knowledge. (Nurse)

A learning orientation, and confidence in one’s own expertise, facilitated speaking up across role boundaries.

I think, earlier on in my career… in the past, that has been the case sometimes, whereby you don’t ask a question or, or speak, speak an opinion because you’re you’re fearful of exposing a hole in your knowledge. But that as someone who is now fairly experienced, I in my career, I’ve reached a point where I don’t fear that in the same way that I might have done five or 10 years ago. I’m much more comfortable with myself. I know what I do know, and I have a fair idea of what I don’t know. And I can reason with that according to my professional role. (Perfusionist)

Team members reflected on how they could express opinion when speaking up directly felt less comfortable—indicating alternative strategies to voicing their concerns, like framing the concern as a question.

I think the way in which I bring something up would change depending on how comfortable I feel about bringing that particular idea or opinion up. […] according to my own nature, and how I see myself within the team, it’s most likely that I would challenge a point of view, challenge a point of view by raising a question rather than forcefully delivering an opinion. (Perfusionist)

Leadership

Team leadership is necessary for a team to function, and the nature of the approach to leadership was seen as consequential for psychological safety within the team and willingness to speak up. Although the intensivist is usually considered the ECMO team leader, an ECMO retrieval is a complex process filled with uncertainty; in such environments, the leadership may be delegated to other team members. During cannulation, for example, the intensivist is task focused and the nurse or the perfusionists may have a better global awareness of what is happening. In this team, leadership was articulated through expertise, knowledge and clinical experience rather than assigned by an individual’s position in the organisation.

There can also be hierarchies based upon clinical expertise and experience, which is necessary in terms of team leadership. (Perfusionist)

Irrespective of their institutional role, team leaders were seen to have a crucial role in setting the right tone for communication and promoting voice within the team. A coaching leadership style was preferred by staff as a way of facilitating sharing of opinions, ideas and concerns.

[Asking] What do you think? you know, this question makes us really feel better. […] That question is very important. (Nurse)