When routine becomes stressful: A qualitative study into resuscitation team members’ perception of stress and performance

ABSTRACT

Interprofessional teamwork is of high importance during stressful situations such as CPR. Stress can potentially influence team performance. This study explores the perception of stress and its stressors during performance under pressure, to be able to further adjust or develop training. Healthcare professionals, who are part of the resuscitation team in a large Dutch university medical center, discussed their experiences in homogeneous focus groups. Nine focus groups and one individual interview were conducted and analyzed thematically, in order to deepen our understanding of their experiences. Thematic analysis resulted in two scenarios, routine and stress and an analysis of accompanying team processes. Routine refers to a setting perceived as straightforward. Stress develops in the presence of a combination of stressors such as a lack of clarity in roles and a lack of knowledge on fellow team members. Participants reported that stress affects the team, specifically through an altering of communication, a decrease in situational awareness, and formation of subgroups. This may lead to a further increase in stress, and potentially result in a vicious cycle. Team processes in a stressful situation like CPR can be disrupted by different stressors, and might affect the team and their performance. Improved knowledge about the stressors and their effects might be used to design a training environment representative for the performance setting healthcare professionals work in. Further research on the impact of representative training with team-level stressors and the development of a “team brain” might be worthwhile.

KEYWORDS:

• Performance
• resuscitation
• stress
• teams
• teamwork

Introduction

Interprofessional teamwork is of high importance in potential stressful medical emergencies, for example during cardiopulmonary resuscitation (CPR) (Hunziker et al., 2011). CPR is a medical emergency where in-hospital team members are alerted and rush toward an in-hospital cardiac arrest, or toward an out-of-hospital cardiac arrest presented in the emergency department. During CPR, immediate actions can be life-saving and are time-critical at the same time, with little or no margin for errors (Crowley et al., 2020; Idris et al., 2015). Resuscitation teams have to perform optimally to achieve the highest possible chance of survival of a patient (Conlon & Abella, 2019). To achieve an optimal performance during CPR, the use of technical (e.g. chest compressions, airway management, defibrillation) and non-technical skills (e.g. communication, teamwork, leadership) are necessary and related (Briggs et al., 2015; Gordon et al., 2012; Hunziker et al., 2011; Nallamothu et al., 2018; Peltonen et al., 2020; Saunders et al., 2021; Yeung et al., 2015). There are a number of challenges however. CPR is performed by an ad hoc assembled team, it is essential that the team perceives a clear division of roles and a shared responsibility in a short period of time. In addition, team members have different areas of expertise which have to be integrated (Reeves et al., 2018) and their particular tasks should be coordinated (Fernandez Castelao et al., 2013). Furthermore, medical emergencies like CPR have the potential of increasing professionals’ experience of stress (Chang et al., 2020; Vincent et al., 2021). Several studies from diverse fields have shown that stress can influence the performance of teams in a negative way (Anderson et al., 2019; Groombridge et al., 2019; Kent et al., 2020). This qualitative study will explore the perception of stress by healthcare professionals who are part of a resuscitation team, in order to create a better understanding of when stress arises during CPR and how it could impact interprofessional team performance.

Background

Stress can be described as a dynamic interaction between a person and the environment (Lazarus & Folkman, 1984). A wide range of experiences or events in a certain environment can lead to the onset of stress (Chrouser et al., 2018). Stress can trigger psychological and physiological reactions that influence the performance of the individual (Vine et al., 2016). It can affect the allocation of attention, the interpretation of information, and the execution of technical interventions (Nieuwenhuys & Oudejans, 2017). These potential effects of stress are well reflected in a wide range of studies from different healthcare professions. For instance, a recent review on the effect of stress on surgical performance revealed the adverse impact of stress on the ability of surgeons’ to gather information and consider options during surgery. Furthermore, due to the stress-induced increase in mental workload, surgeons’ decision making was impaired (Anton et al., 2021). Another review with a specific focus on the influence of stress on CPR showed that the retrieval of previously learned skills, that were learned in a non-stressful setting, was impaired (Vincent et al., 2021). An experimental study in which anaesthetists and anesthesia residents participated in a simulated CPR scenario, demonstrated a decline in non-technical performance in the presence of stressors such as loud noises (Krage et al., 2017). In addition to the studies in simulated settings, a study in a live operating theater using a Black Box demonstrated a direct relationship between the occurrence of acute stress and a decrease in technical surgical performance. Due to the experience of stress, there was an increase in the number of bleedings from a punctured vessel or burns due to touching a structure with a thermal device during the operation (Grantcharov et al., 2019). Altogether, stress seems to have a potentially declining effect on performance of healthcare professionals, which can impact clinical outcomes of patients.

Given the potential consequences of stress on the performance of individuals, and thus on interprofessional team performance, healthcare professionals might benefit from training and education with a distinct focus on performance in stressful situations. Within sports, military and law enforcement, pressure training is accepted as a crucial intervention (Low et al., 2021). Pressure training aims to maintain performance in stressful situations, by having professionals experience a certain amount of pressure during training. Participating professionals have to execute technical skills, make decisions, and simultaneously be able to cope with the experienced stress (Low et al., 2021). Pressure training provides professionals with actions that are feasible and effective under stressful real-life circumstances. Following the concept of representative learning design, introduced by sport psychologists (Pinder et al., 2011) and based on the concept of Brunswik’s representative design (Brunswik, 1956), an important element in the design of a learning environment is the ability of participating professionals to execute certain actions and make decisions in a learning context which includes similar information as the real performance environment. The importance of a realistic learning environment implies that stressors used in a training should be inherent to the task someone has to perform in real-life. This ensures that practically relevant decisions are trained, possibly leading to better transfer of trained skills (Andersen et al., 2016; Dankbaar et al., 2016).

Improving or adapting existing training and education programs, or even develop new programs, is difficult without the correct contextual knowledge on stress and teams. While it is not yet clear when stress is perceived by members of a resuscitation team and how it impacts team performance (Groombridge et al., 2021) we therefore explore when and why resuscitation team members perceive CPR as stressful, and how potential stressors influence team performance. By conducting this study we hope to create a better understanding of stress during CPR and its impact on team performance. With this knowledge, further adjustment or development of tools such as training might be possible, in order to further improve interprofessional team performance during CPR and possibly other stressful situations.

Methods

Research design

To learn from the experiences of healthcare professionals, we used an explorative qualitative design.

Setting

The setting of our research was a large Dutch university medical center with two locations in one city. On average, each location receives about 300 calls for the resuscitation team each year. Cases for which the resuscitation team is alarmed range from OHCA including traumatic cardiac arrest, to in-hospital cardiac arrests on wards and other clinical departments.

A resuscitation team in the participating hospital consists of an anesthetist (consultant and specialist registrar), a cardiologist (consultant and/or specialist registrar), a consultant emergency medicine, an emergency nurse, an anesthesia nurse, and one or two cardiac care nurses. Occasionally, a consultant or specialist registrar and nurses from the Intensive Care Unit are part of the team as well. Team members differ each day, so team members do not know who else is part of the team that day. They only find out when they meet each other during CPR.

Participants and recruitment

Potential participants were, based on their experience as a member of the resuscitation team and thus being knowledgeable on the topic of interest, contacted by HS via e-mail or in-person. We aimed for a sample most representative of actual resuscitation teams. This included fully trained professionals, and trainees such as specialist registrars or nursing trainees. Recruitment took place between April and June 2019.

Data collection

We conducted focus groups, to create interaction and discussion between participants in order to deepen our understanding of their experiences (Stalmeijer et al., 2014). To create a psychological safe environment where people feel free to express their perspectives and opinions, we organized homogeneous focus groups, grouped by specialty and function. Because of a limited number of responses from the medical staff of the intensive care, we chose to conduct an individual interview with that single respondent.

Prior to the focus group we developed an interview guide. Based on existing literature, and brainstorm sessions within our interprofessional research team, a list of topics was generated and refined through discussion with MM, PR, AC and FD. Then topics were discussed with HS, who is a subject matter expert (anesthetist). This resulted in further refinement of the topics and development of an interview guide. After a pilot session with four experienced healthcare professionals, a few minor changes were made to the interview guide. For the final interview guide, see Additional File 1.

Each focus group started with the question to individually describe characteristics of a stressful and non-stressful resuscitation on a post-it. Then each contribution was discussed. The input was used as a starting point for the focus group discussion (King et al., 2013) which also guaranteed that more silent, introverted participants could equally contribute in comparison with more extroverted participants.

Audio-recorded focus groups were conducted in Dutch and took place in a conference room or other available, neutral room at the hospital where the participants worked. Prior to the start of the study, no relationship was established between the researchers who conducted the focus groups (FD and/or PR) and the participants. At the start of the focus groups, participants were informed about the research goals, and the professional background of both researchers. Because of her medical background and experience with resuscitation, FD had the possibility to relate to the topics discussed in the focus groups.

Data analysis

Audio-recordings were transcribed verbatim and data were managed using Atlas.ti. We used template analysis, a form of thematic analysis where a high degree of structure in the analysis process is combined with flexibility (Brooks et al., 2015). This resulted in the following analytical steps: (1) familiarization with the data; (2) preliminary open coding of the data; (3) organization of topics in meaningful clusters by three researchers (FD, PR, AC); (4) design of initial coding template, followed by application of coding template on new dataset; (5) discussion and adaptation of coding template in team sessions (FD, AC, PR and MM); (6) coding of complete dataset with the final coding template, following a selective coding approach. Figure 1 shows our final template in mind map style, illustrating the content of each code; (7) discussion and analysis of the selective coding (with FD, AC, PR and MM). Throughout the complete dataset, our codes (and their content) were interrelated in different ways. In iterative cycles, we analyzed and discussed these scenarios. We felt our findings were sufficient to answer the original research questions, leading to the main findings as reported in the Results section.

Figure 1. Coding template in mindmap style; illustrates content of each code.

Meetings with HS, who has knowledge and experience as a resuscitation team leader, were used as an additional perspective and analytical check.

Ethics

The medical ethics review committee of Amsterdam UMC location VU (registered as IRB00002991) declared that the Medical Research Involving Human Subjects Act (WMO) did not apply to our study (reference number 2019.035). We obtained informed consent from all participants, through a signed form indicating the goal of the focus groups, and the fact that all focus groups were recorded, transcribed and depersonalized. Only FD had access to the raw data.

Reflexivity

The six researchers in this study have different professional backgrounds: FD is trained as a medical doctor, experienced in resuscitation and simulation-based education. AC is a qualitative educational researcher with a background in linguistics, with ample experience as a communication teacher. HS is a medical doctor specialized in anesthesiology, with a research background in resuscitation. MM is a professor in education sciences and head of department. PR is a human movement scientist, specialized in the effects of stress on performance.

This richness of backgrounds in the research team has contributed to the explorative, open-minded approach of the theme. The different analytical perspectives helped to make methodological choices, balance our research findings, and interpret our results. In conducting the focus groups, familiarity with resuscitation helped in understanding the different steps during CPR and the jargon used. Since there was no personal or professional relationship between the researchers who conducted the focus groups and the participants, inherent power dynamics were absent. However, the topic stress can carry a sensitive load, which did make us constantly aware of any power dynamics within the group of participants.

Findings

Demographics

Between April 2019 and November 2019, we conducted nine focus groups with medical staff and medical residents in anesthesia, cardiology, and emergency medicine; nurses of the cardiac care unit, the emergency department, intensive care, and anesthesia; and one individual interview with a medical staff member of the intensive care unit. The number of participants in each focus group ranged from 2 to 25 (mean 6.44; median 5). Duration of the focus groups and interview ranged from 22 minutes to 93 minutes (mean 60 minutes; median 60 minutes). For additional information on the focus groups and their participants (e.g. gender and age of participants), see Table 1. Additional file 2 includes an overview with the number of quotations per code per focus group, supplemented with example quotations.

Table 1. Information on the focus groups and their participants.

	Number of participants in focus group	Duration of focus group/interview	Gender	Age in years	Years of experience in CPR team
Medical staff anaesthesiology	5	90 minutes	F: 2 M: 3	37 to 46 (mean: 42)	9 to 15 (mean: 13)
Medical residents anaesthesiology	5	66 minutes	F: 2 M: 3	27 to 40 (mean: 33)	1 to 8 (mean: 4)
Nurses anaesthesiology	5	93 minutes	F: 2 M: 3	44 to 61 (mean: 54)*	15 to 28 (mean: 20)**
Medical residents anaesthesiology	4	84 minutes	F: 0 M: 4	#	#
Medical staff & residents cardiology	4	34 minutes	F: 1 M: 3	34 to 40 (mean: 36)	4 to 7 (mean: 5)
Nurses coronary care unit	5	38 minutes	F: 4 M: 1	29 to 63 (mean: 40)	3 to 13 (mean: 7)*
Nurses emergency department	3	70 minutes	F: 3 M: 0	29 to 51 (mean: 44)	3 to 27 (mean: 15)
Medical staff emergency department	2	53 minutes	F: 0 M: 2	35 to 43 (mean: 39)	7 to 17 (mean: 12)
Nurses intensive care unit	25	22 minutes	F: 21 M: 4	23 to 55 (mean: 32)*	0 to 18 (mean: 3)**
Medical staff intensive care unit	1	56 minutes	M: 1	55	19

*missing value on age of one or more participants.

#missing values on age and years of experience of all participants.

**missing value on years of experience of one or more participants.

Routine, stress, and how stress affects the team

Analysis of the data resulted in the construction of two scenarios, routine and stress, and an analysis of the accompanying team processes: how stress affects the team. Most participants reported that CPR often proceeds straightforward, by following a clear step-by-step protocol. Such scenarios were thematized as routine. On the other hand, participants reported that CPR may also proceed differently than expected, which can lead to stress. Such scenarios were thematized as stress. An example of these scenarios can be found in Box 1 and Box 2. How potential consequences of stress on team processes and team performance were described, were thematized as how stress affects the team.

Box 1. Example of cardiopulmonary resuscitation perceived as routine

CPR perceived as routine

“Prior to the arrival of the ambulance with the patient, there is a clear announcement. This allows time for the team to prepare, get things ready, and agree on who will do what. In the ideal setting there is a maximum of 6–8 people present, with sufficient knowledge and experience. There is clear and unambiguous leadership, everyone knows how to carry out their tasks and who does what. This gives confidence.” Example of cardiologist, hospital 1

Box 2. Example of cardiopulmonary resuscitation perceived as routine

CPR perceived as stressful

“During the transfer of a patient by the ambulance, one of the other team members immediately starts connecting the patient to equipment, and another team member makes a comment about the lifting mat. Experienced as a disturbance, this creates the feeling of a false start right away. In combination with working with unfamiliar team members, this could lead to the perception of stress.” Example of specialist registrar anaesthetist, hospital 2

Scenario 1 - Routine: resuscitation perceived as straightforward

In all focus groups, participants described CPR in general as a straightforward situation where adherence to the protocol is key. Participants claimed they might encounter some issues during CPR, for example a difficult airway, but in a fluent ongoing process, none of these potential struggles yields a disturbance worth mentioning. Positive contributing factors to the perception of CPR as routine were predictability, leadership, communication, atmosphere and a shared perception of teamwork.

A lot of people find it exciting, but it’s actually the most protocolized thing there is (Q1-FG2 - specialist registrar anaesthesiology)

According to the participants, a routine CPR is characterized by a clear and concise pre-alert by the ambulance, arrival of the team before arrival of the patient, and time to agree on a plan and anticipate possible problems in advance. As soon as the patient arrives (in case of an out-of-hospital cardiac arrest), hands-off positioning of all team members is deemed important. Instead of going straight to intravenous lines or attaching pads to the patient, complete focus on the hand-over by the ambulance helps throughout the complete CPR-setting.

During a routine CPR, the team leader displays tranquility through which he or she can influence the atmosphere in the team. Efficacy of the team leader is characterized by hands-off positioning, demonstrating a helicopter view of the situation, having the right expertise and communicating clearly and calmly.

To me, a leader is someone who observes, sees how he or she can put in the best use of the team (Q2-FG4 - cardiologist)

Communication is not only important for the team leader, but there should also be clear communication within the team.

As long as you keep communicating with each other. Because when that disappears, it becomes a mess. And communicating is something you have to do as team leader, but the other team members as well. And as long as you keep that, usually there is no problem. (Q3-FG7 – consultant emergency medicine)

Although it is not a typical characteristic of a routine CPR, participants mentioned the importance of a pleasant atmosphere in the team. Personal knowledge on fellow team members and feeling the space to be able to make an occasional lighthearted remark, helps to create this atmosphere.

But dedicated teams obviously work; if you know each other, you know what someone does in his or her spare time, and you know what he or she can or can’t do, that works. (Q4-FG2 - specialist registrar anaesthesiology)

The atmosphere then is just - if someone has a very calm way of communicating, that just resonates throughout the team. (Q5-FG5 – cardiac care nurse)

The sense of CPR being a team effort, including the space to correct and complement each other, is another contributing factor. There are some nuances between different types of professions with regard to this sense of team effort. On the one hand, a few participants felt the importance of team familiarity and shared responsibility (Q6-FG7). On the other hand, a strict chain of command (Q7-FG8) was deemed necessary by participants who were often in a more leading role during CPR.

I don’t know if you necessarily have to practice more often, but just that you know each other longer, and also – and I think that helps – that you dare to make mistakes with your colleagues. What I think is important is that you can share that responsibility a little bit, and not pull it all towards you. And that’s easier when you know each other. (Q6-FG7 – consultant emergency medicine)

Well, that you have to ensure not only the militaristic, hierarchical orders, but also the other way around. So you have to ensure not only that what you say is actually done, or that it is carried out. You also have to make sure that you are not that militaristic, giving an atmosphere of -okay, then I won’t say anything anymore-. (Q7-FG10 – consultant intensive care)

Good leadership, good followership, do your task and if you – just stick to your task and if you don’t have anything to do for a while take a step back, you’ll get a new task when it is needed. (Q8-FG8 – consultant anaesthesiology)

Scenario 2 - Stress: resuscitation perceived as stressful

When participants were asked about stress during CPR, they did not recognize CPR as a particularly stressful situation at the start of the focus groups. However, as the conversation proceeded, it turned out that everyone had experienced certain stressors that could disrupt the team process. In most of the described stressful situations, participants mentioned there was not just one specific stressor, but often combinations of a few stressors had a potential deteriorating effect on the whole team process.

The moment you get so overwhelmed by your feelings, then it’s no longer routine at all. (Q9-FG2 - specialist registrar anaesthesiology)

Participants described this scenario as characterized by a feeling of not knowing each other, a lack of clarity toward role- and task division, and the emergence of uncertainty. Uncertainty may be toward fellow team members or the team leader, arising when one perceives that a colleague cannot perform the skills for which he is part of the team, or performs poorly.

Well, if you don’t know them, they’re insecure, and they can’t do what they’re coming for. (Q10-FG1 - specialist registrar anaesthesiology)

In addition, there may also be uncertainty toward the process: questioning the direction the process is headed, or the feeling everything is at a standstill. This lack of clarity and knowledge and the resulting uncertainty could culminate in a vulnerability for other factors. Circumstances that are normally not disruptive can suddenly upset the process during CPR (Q11-FG2). Participants mentioned logistical issues such as a surplus of people in the shock room, complicated technical interventions and nonfunctioning equipment as examples.

Creating an open airway for example, or inserting a difficult intravenous line. Often that is quite easy, but if that becomes difficult, in combination with a certain amount of time pressure to start the whole process because you feel there is something to win, I believe those are difficult moments as well. (Q11-FG2 - specialist registrar anaesthesiology)

You have this many people doing a part of the workload, and there is only this much room for people to be with the patient. Yes, everything will be outsourced to the nurses running around the patient. You have sort of a net overload actually”. (Q12-FG3 – anaesthesia nurse)

In a trauma setting, you always have that X-ray device where you have to squeeze in between, so to speak. It’s side conditions that make it more difficult. (Q13-FG 6 – emergency nurse)

Although communication can be very helpful in teamwork, participants perceived communication as a potential stressor as well, in particular when different communication patterns develop and people start talking right through each other.

What I really think is stressful, is when people are talking out loud through each other – you do not know anymore what everyone is doing. (Q14-FG5 – cardiac care nurse)

Analysis of team processes - How stress affects the team

As a result of the perception of stress within the team, participants described some substantial changes in the team process. Overall, these changes mainly related to communication, overview and subgroup formation.

Participants reported an important change in communication in the team due to stress: there is a move toward one-way communication. This might result in an increased risk of important messages not being heard, and in the end in less effective team performance as well.

When there is stress, there seems to be a move towards sending messages instead of listening to each other. And we all have it, but that means that at a certain moment a lot of messages are being sent and not so much is being received. And that results in a less effective team. (Q15-FG8 – consultant anaesthesiology)

Another important aspect that changed within the team is the overview of the situation. In a stressful CPR-setting tasks are handed over or being switched between team members, or team members have an increased focus on their own tasks. This can lead to a decreased overview of the complete situation, for the whole team.

Everybody is rumbling around each other, tasks are handed over like: hey, can you give it a try? Tasks are being switched, you lose people. (Q16-FG2 - specialist registrar anaesthesiology)

Subgroup formation (or “islands”) was described as a potential influential change for team performance as well. Specifically by checking out of the team and into the focus for a specific technical task, there is a chance of creating subgroups within the team. In an already stressful situation, the team process can become more difficult due to a lack of communication between subgroups and a decrease in overview for the team. The resuscitation is no longer a team effort.

What is happening is that you’re going to have teams within a big team, so everyone is going to talk louder and louder and people are going to scream at some point. And the people who are saying really important things, you don’t hear them anymore. (Q17-FG8 – consultant anaesthesiology)

When participants described how stress influenced the actual team process, they acknowledged that this could also enforce the stressors mentioned before. A concrete example is a CPR-setting with so many people around, “it becomes a mess, you’ll lose people, the leader has lost the overview” (FG 3 anesthesia nurse). And “with so many orders you get, it is difficult to make a selection” (FG 3 anesthesia nurse). Some participants mentioned they experienced uncertainty due to a situation like this, risking a further increase of stress.

Discussion

The aim of this study was to investigate how stress emerges during CPR and how stress could impact the performance of a team. We organized nine focus groups and one individual interview with members of in-hospital resuscitation teams. Through a qualitative analysis we organized the data in both routine and stressful scenarios, and an analysis of what happens in the team when the stress levels rise. The findings gave insight into when and why members of a resuscitation team perceive CPR as stressful, what stressors are important and how these stressors influence performance.

Most participants explained that CPR often proceed straightforward. A routine situation is often characterized by time and space to anticipate on teamwork, a recognizable clinical case and potential actions; efficacy of the team leader; clear communication and a pleasant atmosphere. Adherence to the protocol is key. However, not every CPR-setting is perceived as routine. Participants described a lack of clarity in team roles and associated tasks, but also a lack of knowledge on your fellow team members, as difficult and potentially stressful. A variety in professional background and training experience, but also differences in the approach of teamwork might result in different and challenging communication patterns. Technical problems such as a complicated airway, or logistical challenges like too many people in a small room may add to the perception of stress. It appears that these stressors are interrelated in different ways, potentially resulting in a deteriorating effect on the process as a whole. Participants reported that stress affects team performance, resulting in an altering of communication, a decrease in situational awareness, and formation of subgroups. When participants described how stress influenced the actual team process, they acknowledged that experienced stress could also enforce the effect of aforementioned stressors during CPR, suggesting a potential vicious cycle.

Previous studies within and outside the domain of healthcare reported similar findings on the influence of stress on team performance: a narrowing of attention, experienced difficulties with decision-making and a decrease in technical performance (Dietz et al., 2017; Dijkstra et al., 2021; Groombridge et al., 2021; Ng et al., 2019; Nieuwenhuys & Oudejans, 2017; Piquette et al., 2009; Wemm & Wulfert, 2017). The additional value of our study is on the when and how: when does stress arise during CPR, and how does it affect the team? Although characteristics of a CPR-setting itself, such as patient characteristics, technical difficulties, or interaction with family members, could function as stressors, our study also reveals the interplay of different factors at different moments and the importance of potential stressors on a more relational-/team-level. The when and how emphasize the complexity of teamwork in stressful situations, but it also provides insight into potential adjustments or improvements for training, in order to create high performance teams.

In developing functional training for resuscitation teams, the answer to when does stress arise? is important to create a correct representation of the real world in which healthcare professionals have to perform. Considering the representative learning design, training should be high in action fidelity: “a degree of association between behaviour in an experimental task with that of the performance setting to which it is intended to generalize” (Pinder et al., 2011). When focusing on our studied performance setting, CPR, the inter-relational complexity of the real world should be represented as well. Sharma et al. (2011) suggest an important role for sociological fidelity in training. Sociological fidelity implies that the complex clinical context for which healthcare professionals have to perform their new acquired skills should be acknowledged, next to skill acquisition (Sharma et al., 2011). Performance influencing factors such as social relationships, professional identity and hierarchy should be integrated in the development of training scenarios (Boet et al., 2014; Sharma et al., 2011) thereby representing the context healthcare professionals work in. Our findings suggest that CPR is not always the routine situation professionals often train for. A training design for CPR, as described by our participants, for example embeds personal relationships (or the lack of it) between team members, the uncertainty participants can perceive due to poor performance of a colleague, disrupted communication patterns, or the lack of overview by a team leader or the complete team.

Our findings show that experiencing stress can result in changes in communication, and difficulties with maintaining an overview of the situation. In previous research, we suggested that developing a “team brain” might help to mitigate the effect of stress on teams (Dijkstra et al., 2021). This team brain refers to a concept that encompasses situational awareness (observation and interpretation of clinical event and anticipation on the future (Endsley, 1995; Evans et al., 2021), shared mental model (individual cognitive representation of goals, processes and roles within the team (Evans et al., 2021; Floren et al., 2018), and transactive memory system (shared memory network, formed through communication about expertise) (Fernandez et al., 2017; Yan et al., 2020). While teamwork in stressful situations does not revolve solely around situational awareness or a shared mental model, the three concepts together (referred to as team brain) are important for preparing for and performing in potential stressful situations. The results from our study confirm this picture. On the one hand, participants clearly indicated that sufficient preparation time to talk through the case helps. And when team members know each other, know what they can expect from each other, and can anticipate on the future, CPR feels like a team effort. On the other hand, participants mentioned that stress could arise in uncertain circumstances, for example when you do not know a fellow team member and what you can expect of him or her. And when actual stress is experienced, it seems difficult to maintain an overview of the situation.

Incorporating our findings and the above mentioned concepts, we would like to focus on the distinction between preventing the development of potential stressful circumstances, and maintaining performance when a stressful situation still occurs (Nieuwenhuys & Oudejans, 2011). Concretely, this means that teams should invest in development of a team brain in order to prevent the emergence of stress, but also in skills to maintain a team brain in stressful situations. The interplay of stressors, and the potential vicious cycle that could arise, is the reality that professionals should train for. One focus point for training could be the role of knowledge on your fellow team members, in literature often referred to as “team familiarity” (Kurmann et al., 2014; Stucky & De Jong, 2021). Our participants related familiarity to knowing each other’s name, role and task, expertise, and personal background. Positive consequences of familiarity were a feeling of being safe to make mistakes, but also to correct and complement each other. Investing in team familiarity therefore seems worthwhile, in order to reach a team brain. A means to do so can be more frequent interprofessional training sessions with a focus on gaining knowledge of each other’s personal and professional background. Furthermore, actions that can be carried out at the start of or during a shift might be convenient as well. For example, Purdy et al. (2022) suggested shift huddles, team briefings and after action reviews that might build “just-in-time familiarity” (Purdy et al., 2022). However, we would like to argue that training a scenario where team members do not feel familiar with each other and potential disruptions arise, is important as well. Such a scenario could result in a setting that incorporates the complex social context our participants recall (= sociological fidelity), with stressors inherent to the task that has to be performed in real-life (= representative learning design).

Note that we do not claim that being attentive to fellow team members on itself saves lives. Professionals will have to keep training life-saving actions. However, we argue that these actions need to be trained in a representative context, namely those situations that professionals perceive as difficult and potentially stressful. We believe that this approach might be transferrable to other potential stressful situations, for example a rapidly deteriorating patient in the operating room. However, further research into the exact potential stressors in these situations is necessary in order to design training scenarios.

Strengths and limitations

One of the strengths of our study, is our effort to study and understand real experiences of healthcare professionals. However, these real experiences had to be recalled by participants, and certain aspects of resuscitation attempts might change over time when the case happened a while ago. Also, although we perceived an open atmosphere during the interviews, sometimes we noticed a certain threshold in our respondents to express feelings concerning stress and work. Nonetheless, after further questioning the different feelings and perceptions regarding stress clearly emerged. In order to prevent reactions from participants being taken for granted too quickly, we tried to conduct the interviews collectively with two researchers. Due to circumstances this did not always succeed. The first three focus groups were conducted together, which made the subsequent focus groups manageable for one researcher. Throughout all focus groups we were able to follow the (piloted) interview guide, which left us enough time and space to listen, ask and respond to what was said, and reach sufficient depth. As participation in our study was voluntary, perhaps a specific subset of team members responded to the invitation. This is reflected in the varied number of participants in each focus group, ranging from 2 to 25, with a median of 5. With regards to the focus group with 25 participants, we are aware that this has not been the most in-depth conversation. However, because of the difficulties with scheduling an appointment, we still decided to continue the focus group in this form. Even though it is not as comprehensive as we had hoped, we did manage to include the voices of ICU-nurses on the topic of stress and team performance.

Conclusion

While stress can have a significant influence on team performance during cardiopulmonary resuscitation, we aimed to gain insights into the personal experiences of situations where stress did or did not evolve and how this impacted performance. A combination of team-level stressors, such as a lack of clarity in roles and a lack of knowledge on fellow team members, can fuel the development of stress. Because team performance can be affected by stress, and a subsequent vicious cycle can develop, it seems worthwhile to invest in representative training designs with a specific focus on the identified stressors and their consequences. This has the potential to improve resuscitation team performance in clinical practice. Further research is needed to determine the impact of this type of training on the team-level stressors and the development of a “team brain,” in order to create the high-performance teams our patients need.

Acknowledgments

We would like to thank the participants in our study, who gave up their time to be interviewed. Furthermore, we would like to thank dr Ralf Krage for his assistance in recruitment.

Disclosure statement

HS reports grants to his institution from Stryker Emergency Care, the Zoll Foundation and the AMC Foundation, all outside the scope of this study. The other authors have no conflicts of interest to report.

Additional information

Funding

FD received a research grant from the Dutch Research Council (NWO), grant number 023.009.064.

Notes on contributors

FS Dijkstra

FS Dijkstra is a PhD-student in Educational sciences and a lecturer in nursing education. Her research interests are interprofessional teamwork, stress and simulation-based education.

A de la Croix

A de la Croix is a qualitative educational researcher with a background in linguistics. Her main research interest is stimulating reflection in health professions education.

H van Schuppen

H van Schuppen is an anesthesiologist, with a research background in resuscitation. His research interests include prehospital care, human factors, and organization of the chain of survival.

M Meeter

M Meeter is a professor in education sciences and head of department. His research interests are personalized learning, learning analytics and student motivation.

PG Renden

PG Renden is a human movement scientist and a senior lecturer in nursing education. His research interests are professional performance, stress and perceptual motor learning.