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I become your extended arms: how distance and technology redefine teamwork in rural distributed emergency teams
Umeå University, Faculty of Medicine, Department of Nursing.ORCID iD: 0009-0006-3696-8947
2025 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Jag blir dina förlängda armar : hur avstånd och teknologi omdefinierar teamarbete i rurala distribuerade akutteam (Swedish)
Abstract [en]

In rural areas of Sweden, with limited resources and long distances between homes and services, small cottage hospitals (Sjukstugor) are essential for meeting the population’s needs. Emergency care is provided around the clock by a team of staff members, not all of whom work from the cottage hospital during on-call hours. The team’s physician operates remotely, while the registered nurse and nurse assistant are physically present with the patient. This situation is commonly referred to as a distributed team, in which some members carry out their duties in person at the location while others participate in team collaboration via video conferencing. Even though teamwork is crucial for patient safety, there is currently a lack of knowledge on how distributed teams perform in comparison with co-located teams. This thesis explores teamwork and taskwork in distributed teams during emergencies in rural healthcare. The research consists of four studies. 

Study I is a literature review that thematically analyses relevant research to map the current knowledge of teamwork in distributed settings. Study II assesses the reliability and validity of an instrument for assessing team performance. Study III then uses this validated instrument to examine differences in team performance between distributed and co-located teams in simulation-based team training, employing statistical methods to compare these teams. Study IV uses a qualitative method to analyse focus group interviews with staff in distributed teams. It analyses their experiences in distributed teamwork and the language they use to describe their experiences.

Study I shows that distributed teams perform well when the technology is reliable and team members have received relevant training. Leadership is crucial for creating a sense of community and trust among team members, while communication via technology requires more time and clarity. The workload increases in distributed settings, and familiarity among team members plays an important role. Study II confirms the instrument’s reliability and validity for measuring team performance in the distributed setting. Study III demonstrates that co-located teams perform better than distributed teams in emergencies overall. In Study IV, staff narrate their experiences in distributed settings, with registered nurses describing their expanded responsibilities as both challenging and stimulating. General practitioners value remote leadership but miss hands-on examinations, while nursing assistants note a closer patient connection with the general practitioners participating remotely.

The main findings indicate that, while there are similarities in teamwork between co-located and distributed teams, distributed teams face additional challenges in achieving effective team performance. Strategic training for staff working in distributed settings should be a key objective. This training should focus on using technology effectively to facilitate verbal and non-verbal communication. It should equip registered nurses to handle more clinical tasks and take on greater responsibility in the absence of a general practitioner. Furthermore, leadership training should focus on engaging and uniting the team towards common goals. A central challenge is how shifting roles and responsibilities in distributed teams can lead to increased workloads and potential conflicts, requiring the development of strategies to promote collaboration and minimise tension within the team. 

Abstract [sv]

I den här avhandling utforskas hur teamarbete och arbetsuppgifter påverkas i akuta sjukvårdsteam var medlemmar är skilda åt av geografi och som samarbetar via tekniska lösningar i glesbygdsområden. 

I Sveriges glesbygdsområden, där långa avstånd och begränsade resurser utgör stora utmaningar för hälso- och sjukvården, spelar sjukstugor en viktig roll för att möta invånarnas behov. I dessa områden erbjuds akutsjukvård dygnet runt av personal som under jourtid inte arbetar på samma plats. Läkaren finns på distans medan sjuksköterska och undersköterska är på plats med patienten och samarbetet sker via videokonferens i så kallade distribuerade team. Trots att teamarbetets kvalitet är avgörande för patientsäkerhet, saknas idag kunskap om hur distribuerade team fungerar jämfört med samlokaliserade team, där alla teammedlemmar befinner sig på samma plats. 

Avhandlingen består av fyra delstudier. Studie I är en litteraturöversikt där relevant forskning samlades in och analyserades tematiskt för att kartlägga kunskap om teamarbete i distribuerade team. I Studie II genomfördes statistiska analyser av ett instrument som mäter teamarbete för att säkerställa tillförlitlighet och giltighet även för distribuerade team. Instrumentet användes därefter i Studie III för att statistiskt jämföra skillnader i teamarbete mellan distribuerade och samlokaliserade teamarbetssituationer. I Studie IV användes en kvalitativ metod för att analysera fokusgruppsintervjuer med personal, med syfte att utforska deras erfarenheter och hur de talade om distribuerat teamarbete.

Studie I visade att distribuerade team kan samarbeta väl när tekniken är tillförlitlig och teammedlemmarna har fått relevant utbildning. Ledarskap var avgörande för att skapa en känsla av gemenskap och förtroende, medan kommunikation via synkrona tekniska lösningar krävde mer tid och tydlighet. Arbetsbelastningen ökade i distribuerade team, och om man tidigare hade arbetat med teammedlemmarna underlättade det samarbetet. Studie II bekräftade instrumentets giltighet och tillförlitlighet för att mäta teamarbete i distribuerade team. Studie III visade att samlokaliserade team överlag presterade bättre än distribuerade team i akuta situationer. I studie IV beskrev personal sina erfarenheter i distribuerade miljöer (där läkaren arbetade på distans). Resultatet visade att sjuksköterskorna fick ett ökat ansvar som uppfattades både utmanande och stimulerande. Läkarna uppskattade möjligheten att leda på distans men saknade förmågan att utföra kliniska undersökningar, medan undersköterskor noterade en närmare patientkontakt när läkaren deltog på distans.

Huvudresultatet i denna avhandling visar på många likheter i teamarbetet mellan samlokaliserade och distribuerade team, däremot möter distribuerade team fler utmaningar för att uppnå ett välfungerande samarbete. Kontinuerlig utbildning för personal som arbetar distribuerat är viktigt. Utbildningen bör fokusera på att använda tekniska lösningar effektivt för att underlätta interaktioner, både verbal och icke-verbal kommunikation samt ge sjuksköterskor träning i att hantera fler uppgifter och större ansvar i läkarnas fysiska frånvaro. Dessutom bör ledarskapsutbildningen syfta till att engagera teammedlemmarna mot gemensamma mål. En central utmaning är hur förändrade roller och ansvar kan leda till ökad arbetsbelastning och konflikter, vilket kräver strategier som främjar samarbete och minskar spänningar i teamet.

Place, publisher, year, edition, pages
Umeå: Umeå University, 2025. , p. 84
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2329
Keywords [en]
Rural area, cottage hospital, community hospital, distributed teams, telemedicine, teamwork, scoping review, validity, cross-over, simulations, focus groups, discourse psychology
National Category
Nursing
Research subject
Caring Sciences
Identifiers
URN: urn:nbn:se:umu:diva-233888ISBN: 978-91-8070-554-7 (print)ISBN: 978-91-8070-555-4 (electronic)OAI: oai:DiVA.org:umu-233888DiVA, id: diva2:1926330
Public defence
2025-02-07, Aula Biologica, Biologihuset, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2025-01-17 Created: 2025-01-10 Last updated: 2025-01-13Bibliographically approved
List of papers
1. Mapping leadership, communication and collaboration in short-term distributed teams across various contexts: a scoping review
Open this publication in new window or tab >>Mapping leadership, communication and collaboration in short-term distributed teams across various contexts: a scoping review
2024 (English)In: BMJ Open, E-ISSN 2044-6055, Vol. 14, no 10, article id e081878Article, review/survey (Refereed) Published
Abstract [en]

Introduction: Increased globalisation and technological advancements have led to the emergence of distributed teams in various sectors, including healthcare. However, our understanding of how leadership, communication and collaboration influence distributed healthcare teams remains limited.

Objectives: This study aimed to map knowledge on leadership, communication and collaboration in short-term distributed teams across various fields to gain insights that could benefit healthcare.

Design: Scoping review.

Data source: A database search of PubMed, CINAHL, Scopus and PsycINFO was conducted in May 2021 and updated in February 2023 and May 2024.

Eligibility criteria: Articles were eligible if they involved leadership, communication or collaboration in distributed short-term teams supported by synchronised audio-visual communication technology. Two researchers independently screened titles, abstracts and full texts for inclusion.

Data extraction and synthesis: Extracted data on leadership, communication and collaboration were synthesised narratively and reported in terms of patterns, advances, gaps, evidence for practice and research recommendations.

Results: Among 6591 articles, 55 met the eligibility criteria, spanning military, engineering, business, industrial and healthcare contexts. The research focus has shifted over time from adverse effects to solutions for overcoming challenges in distributed teams. Inclusive leadership is vital for engaging all team members. 'Team opacity', the absence of non-verbal cues and reduced awareness of team members' actions, can occur in distributed teams relying on technology. Clear communication is crucial for avoiding misunderstandings and fostering collaboration and adaptability. Developing shared mental models and trust is more challenging, leading to uncertainty and reduced information sharing. There is a lack of studies examining how to apply this knowledge to health professionals' education.

Conclusion: Our findings highlight the importance of implementing strategies in healthcare to enhance inclusive leadership and improve communication in distributed healthcare settings. More empirical research is needed to understand the intricacy of distributed healthcare settings and identify effective ways to train distributed healthcare teams.

Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2024
National Category
Media and Communication Studies
Identifiers
urn:nbn:se:umu:diva-231197 (URN)10.1136/bmjopen-2023-081878 (DOI)39448210 (PubMedID)2-s2.0-85207335621 (Scopus ID)
Funder
The Kamprad Family Foundation, 20190292
Available from: 2024-10-25 Created: 2024-10-25 Last updated: 2025-02-17Bibliographically approved
2. Reliability and validity testing of team emergency assessment measure in a distributed team context
Open this publication in new window or tab >>Reliability and validity testing of team emergency assessment measure in a distributed team context
Show others...
2023 (English)In: Frontiers in Psychology, E-ISSN 1664-1078, Vol. 14, article id 1110306Article in journal (Refereed) Published
Abstract [en]

Medical multi-professional teams are increasingly collaborating via telemedicine. In distributed team settings, members are geographically separated and collaborate through technology. Developing improved training strategies for distributed teams and finding appropriate instruments to assess team performance is necessary. The Team Emergency Assessment Measure (TEAM), an instrument validated in traditional collocated acute-care settings, was tested for validity and reliability in this study when used for distributed teams. Three raters assessed video recordings of simulated team training scenarios (n = 18) among teamswith varying levels of proficiency working with a remotely located physician via telemedicine. Inter-rater reliability, determined by intraclass correlation, was 0.74–0.92 on the TEAM instrument’s three domains of leadership, teamwork, and task management. Internal consistency (Cronbach’s alpha) ranged between 0.89–0.97 for the various domains. Predictive validity was established by comparing scores with proficiency levels. Finally, concurrent validity was established by high correlations, >0.92, between scores in the three TEAM domains and the teams’overall performance. Our results indicate that TEAM can be used in distributed acute-care team settings and consequently applied in future-directed learning and research on distributed healthcare teams.

Keywords
interprofessional teams, team performance, teamwork, distributed team, telemedicine, instrument, validation, assessments
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-206995 (URN)10.3389/fpsyg.2023.1110306 (DOI)000979890100001 ()2-s2.0-85158024637 (Scopus ID)
Funder
The Kamprad Family Foundation
Available from: 2023-04-24 Created: 2023-04-24 Last updated: 2025-01-10Bibliographically approved
3. Teamwork in rural emergency health care: A Simulation-Based Cross-over Study of Co-located and Distributed Teams
Open this publication in new window or tab >>Teamwork in rural emergency health care: A Simulation-Based Cross-over Study of Co-located and Distributed Teams
Show others...
2024 (English)In: Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, ISSN 1559-2332, E-ISSN 1559-713XArticle in journal (Other academic) Epub ahead of print
Abstract [en]

Introduction: Despite the increasing use of distributed healthcare teams, performance evaluation is largely lacking. This study examined rural emergency health care in Sweden to determine the effect of teams being either co-located or distributed with remote physicians accessible via telemedicine.

Method: In this crossover study, 17 three-person teams were video recorded during co-located and distributed simulated scenarios. Team performance in the video recordings was evaluated using the TEAM instrument.

Results: Co-located scenarios had significantly higher Total ratings for the instrument (items 1–11), in the teamwork domain (items 3–9), and in overall performance (item 12) compared with distributed scenarios (P < 0.005). Item-level analysis revealed that co-located teams were better at completing tasks on time (item 4) and showed greater adaptability to changing situations (item 7).

Conclusions: The higher rating of the performance of co-located teams underscores the challenges facing distributed teams. Given that distributed healthcare teams are a reality in rural areas in northern Sweden, education and training must be adapted to address these challenges. This adaptation is crucial for ensuring high-quality patient care by distributed teams.

Place, publisher, year, edition, pages
Wolters Kluwer, 2024
Keywords
Teamwork, team performance, simulation, distributed team, TEAM instrument, observations, assessments, rural health care
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-231116 (URN)10.1097/sih.0000000000000831 (DOI)
Available from: 2024-10-24 Created: 2024-10-24 Last updated: 2025-01-10
4. ‘We feel left alone out here’: dilemmas in teamwork among rural health professionals in distributed emergency settings
Open this publication in new window or tab >>‘We feel left alone out here’: dilemmas in teamwork among rural health professionals in distributed emergency settings
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-233886 (URN)
Available from: 2025-01-10 Created: 2025-01-10 Last updated: 2025-01-13Bibliographically approved

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