CALM amid chaos: the art of being a team leader

CALM Leadership approach

To help family physicians working in high-acuity areas cultivate the confidence required to successfully manage a team through a challenging situation,^2-11 I developed a toolkit of skills called the CALM Leadership approach. Adapted below as an easy-to-use checklist, the CALM Leadership approach can be quickly recalled using the acronyms SET, CALM, and PACE (Figure 1).

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Figure 1.

Leadership framework for resuscitation team leaders

SET: Self-check, Environmental scan, and Team pre-brief

SET outlines what to do before an emergency medical situation begins:

1. Self-check: Check in with yourself to mentally prepare to lead. You can use a grounding statement (eg, “I can do this!”) or think of a motivational song to pump yourself up. Assess your physical needs. Do you need a drink or to use the bathroom? Do you need to hand over other patients to focus on this urgent case?

2. Environmental scan: Perform a scene or room assessment using the zero point survey.¹² Do you have the necessary equipment and team members to manage the patient? Prepare all medications and medical equipment you may require. Consider tools you can use to help identify team members (eg, name tags, writing on whiteboard).¹²

3. Team pre-brief: Set the stage and ensure the team is prepared for the patient’s arrival.^2,5,12 You can easily remember key information for this step using the acronym READY:

   • R=Roles and responsibilities

   • E=Emergency medical services hands-off handover

   • A=Action plan (mental model)

   • D=Details of patient

   • Y=psYchological safety

SET in action

Scenario. You are notified of a decompensating patient you need to assess. Gather your team and introduce yourself as the team leader. Assign roles and responsibilities, and highlight priority tasks. Make eye contact and use first names when assigning tasks.

Based on information you have about the incoming patient, state your plan of action. Share a mental model of how things will flow. If you require additional patient information, ask for it. Specifically, ask the lead paramedic transferring the patient, or primary nurse caring for the patient, to clarify important patient details so you can update the team (name, age, allergies, symptoms, vital signs, medications, treatments, etc).^2,5

Create a psychologically safe environment and encourage team members to speak up by saying: “At any time please tell me if you have suggestions or concerns. Your input matters.” Consider the tone and volume of your voice, facial expressions, and body positioning, as this will create the energy in the room and can make team members feel either safe or unsafe. A team that feels safe to speak up can improve patient outcomes, prevent errors, and avoid duplicating tasks.^7,13

Advise the team that, when emergency medical services arrive, you will receive a report from the lead paramedic before moving the patient, ensuring the entire team hears pertinent information.

CALM: Communication, Adaptive awareness, Listening, Managing team dynamics

CALM outlines what to do during an emergency medical situation:

1. Communication: Use concise, closed-loop communication for the team brief, updates, and handover, and to coordinate your action plan. Ensure information is clearly communicated to the person assigned to document the medical emergency (recorder or scribe).

2. Adaptive awareness: Monitor the environment. Is there unnecessary traffic entering the room? Do you need to ask people not actively involved in patient care to leave? Is there someone you should call to assist you? Has the family arrived? Do you need to update a specialist?

3. Listening: Ensure all team members feel heard and are encouraged to offer ideas. Ask them, “What am I missing?”

4. Managing team dynamics: Monitor team dynamics and promptly manage any behaviour that may disrupt the environment (eg, yelling, argumentative responses). Remembering the acronym CUS can help you deal with these situations (Figure 2):

   

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   Figure 2.

   Leading in chaos

   • C=Concerned: “I’m concerned I may miss something, given the volume in the room. Let us try to decrease the noise.”

   • U=Uncomfortable: “I am uncomfortable with our interaction in front of the patient. May we chat outside the room?”

   • S=Safety risk: “It is a safety risk for the patient when I cannot hear others providing essential updates. Let us limit our side conversations.”^7,12

CALM in action

Scenario. Once the patient arrives, identify the lead paramedic and ask them to provide the handover report to the team. Remind the team to listen to the report before transferring the patient to the hospital stretcher. Substantial gaps in patient care can occur during handovers when a team is unfocused, leading to missed information about important things like patient allergies, medications given, primary assessment, and vital signs.^2,5

If the patient is actively receiving cardiopulmonary resuscitation, you can ask the team to transfer the patient to a hospital stretcher while continuing resuscitation, and have the lead paramedic provide handover directly to you. Following the handover report, organize your thoughts and provide a team brief that includes essential updates and an action plan to direct urgent interventions and priorities. The handover report is crucial for setting the stage, establishing situational awareness, and ensuring the team can effectively manage the patient.

As you brief the team, try to situate yourself at the foot of the stretcher to ensure you can see the team, patient, and monitors. This allows you to maintain overall situational awareness and easy access to the telephone, patient test results on the computer, and new team members arriving to support the resuscitation.^4,9

You can now begin patient management or resuscitation. Update the team about critical concerns, required interventions, and priorities of care and transport as you continually reassess the patient, adapting your plan as required.

PACE: Pause, Appreciation, Check in, Explore takeaways

PACE outlines what to do after an emergency medical situation is over:

1. Pause: If the patient died, advise the team and patient’s family there will be a moment of silence to respect the patient.

2. Appreciation: It is important to express your gratitude to the team and thank them for their commitment.

3. Check in: Talk to the team to ensure they are coping well with the situation. Ask team members how they feel and support emotional well-being.

4. Explore takeaways: Consider lessons learned or essential action items to improve future care.

PACE in action

Scenario. After the emergency is managed, consider how you can help the patient’s family, and what can be done to support the team and help them recover. The START Check-in framework¹⁴ can help guide this conversation:

• S=Safe: Establish a safe and supportive environment.

• T=Team-focused: Include all team members in the discussion.

• A=Acknowledge: Verbally acknowledge the team just experienced a challenging situation and thank them for working hard to help the patient. Even if you only have 10 seconds, tell the team you appreciate their efforts.

• R=Reflect: Think about reactions and emotions team members may be experiencing. Ask how they are feeling about the case.

• T=Takeaways: Ask about team members’ plans to recover from the event and recommend they talk to a friend, family member, or health care professional. Offer tips for self-care (eg, exercising, journaling, bath).

The final step after an emergency is to promote learning for the future. You may choose to debrief your team but consider that now may be a sensitive time to hold this type of discussion. Assessing what could have been done better during the emergency may not be optimally discussed after an emotional resuscitation. Ensure any debriefing is focused on functional improvements, like having easy access to a crash cart or ST-elevation myocardial infarction protocol checklist.¹⁵