Conceptual foundations

Several complementary conceptual frameworks help explain why team dysfunction develops and how it affects outcomes in paediatric heart care. The Input-Process-Output model remains a useful organising structure. In this model, inputs include team composition, expertise, staffing, workload, and organisational context; processes include communication, coordination, leadership, conflict management, and shared mental models; and outputs include patient outcomes, efficiency, staff well-being, and family satisfaction. ^{Reference Lilford, Chilton and Hemming13–Reference Toccafondi, Albolino and Tartaglia14} In paediatric heart care, technical expertise alone is insufficient to guarantee strong outcomes because performance depends on how effectively teams exchange information and coordinate action under pressure. Social exchange theory adds a relational dimension by suggesting that cooperation is more likely when individuals perceive fairness, reciprocity, and mutual respect. ^{Reference Wu and Lv15} In hierarchical healthcare environments, clinicians may be less willing to contribute observations when they do not expect those contributions to be valued. This is especially relevant in paediatric cardiac settings, where bedside nurses, trainees, perfusionists, and anaesthesiologists may detect early warning signs before they are visible to the broader team.

Relational coordination theory further emphasises that high-quality performance in interdependent work depends on shared goals, shared knowledge, and mutual respect, reinforced by timely, accurate, and problem-solving communication. ^{Reference Reeves, Pelone and Harrison16} This framework is particularly relevant to paediatric cardiac care because teams must coordinate tightly across disciplines and settings while managing uncertainty and rapid physiologic change. Psychological safety and high-reliability organisation principles extend this analysis. Psychological safety refers to a shared belief that team members can raise concerns, ask questions, or acknowledge uncertainty without fear of humiliation or retaliation. ^{Reference Asante17} High-reliability organisations operate in hazardous environments while maintaining low failure rates by remaining preoccupied with failure, sensitive to frontline operations, committed to resilience, and deferential to expertise rather than rigid hierarchy. ^{Reference Leonard, Graham and Bonacum18–Reference Weller, Boyd and Cumin19} Together, these frameworks suggest that paediatric heart programmes achieve safer outcomes when they support respectful communication, clearly structured processes, and a culture in which expertise can surface regardless of rank (Figure 1).

Figure 1.

Conceptual framework linking team inputs, team processes, and outcomes in paediatric heart care. Structural inputs, including team composition, expertise, staffing, culture, and resources, shape team processes such as communication, situational awareness, role clarity, psychological safety, and coordination. These processes influence outcomes for patients, families, and clinicians.

Mechanisms of dysfunction in paediatric heart care

The most reported mechanism of dysfunction in paediatric cardiac teams is communication failure. Communication breakdowns may occur during operative planning, intraoperative management, postoperative transfer, daily rounds, family updates, or escalation of care (Figure 2). Incomplete information exchange, ambiguity about priorities, failure to confirm critical instructions, and omission of key contextual details can all disrupt coordinated action. ^{Reference Rosen, DiazGranados and Dietz7,Reference Rattray, Flanagan and Militello20,Reference Martins, Martinez, Simões, Barach and Carmona21} Handoffs from the operating room to the cardiac ICU are especially vulnerable because they occur during periods of high cognitive load, competing tasks, and physiologic instability. In such situations, teams may assume that critical information has been communicated when in fact different disciplines hold different mental models of the patient’s status, risk profile, or contingency plan. ^{Reference Göbel, Zwart and Hesselink22–Reference Mills, Neily and Dunn23}

Figure 2.

Mechanisms of team dysfunction across the paediatric cardiac care continuum Potential failures arise across preoperative planning, intraoperative care, ICU transfer, postoperative management, ward transition, and follow-up. Hierarchy, communication failure, and role ambiguity act as cross-cutting risks throughout the care pathway.

Role ambiguity is another frequent contributor to dysfunction. Paediatric cardiac care involves overlapping expertise among surgeons, cardiologists, anaesthesiologists, intensivists, advanced practice providers, nurses, and allied staff. While overlap can increase flexibility, it can also create uncertainty regarding responsibility during emergencies, family communication, decision escalation, or postoperative management. ^{Reference Stone, Aveling and Frean24–Reference Hallet, Jerath and d’Empaire25} When responsibilities are poorly defined, important tasks may be duplicated, delayed, or omitted. Hierarchical barriers compound these problems. Nurses, trainees, and other frontline clinicians may hesitate to challenge senior physicians even when they detect signs of deterioration or inconsistency in the plan. ^{Reference Asante17,Reference Etherington, Burns and Kitto26} Interpersonal conflict and lack of trust may further erode communication and willingness to collaborate. Although task-related disagreement can improve decision quality when managed constructively, unresolved personal conflict distracts clinicians and impairs team cohesion. Finally, these dysfunctions are amplified by the extraordinary cognitive load of paediatric heart care. Clinicians must integrate complex anatomy, dynamic haemodynamics, medication effects, surgical findings, laboratory trends, and family concerns in real time. Under such conditions, effective team structures serve as cognitive support systems that reduce reliance on assumption and help preserve shared situational awareness. ^{Reference Manser27–Reference Blumenthal, Chien and Singer29}

Consequences for patients, families, and clinicians

Dysfunctional team dynamics affect paediatric heart care through both direct and indirect pathways. The most immediate consequence is harm to patients. Communication failures and poor coordination are associated with medication errors, delayed recognition of instability, incomplete execution of care plans, inadequate preparation for postoperative complications, and prolonged recovery. ^{Reference Baker, Day and Salas6,Reference Rosen, DiazGranados and Dietz7,Reference Hughes, Gregory and Joseph30} In paediatric cardiac surgery and critical care, these failures can become clinically significant very quickly because patients often have limited physiologic reserve. Missed nursing care, ineffective escalation, or a delay in communicating intraoperative concerns to the intensive care team may contribute to morbidity, prolonged intensive care unit stay, or avoidable deterioration. ^{Reference Marlow, Hughes and Sonesh31–Reference Kyriacou Georgiou, Merkouris, Hadjibalassi, Sarafis and Kyprianou33} Studies of healthcare teamwork more broadly have consistently shown that better team coordination is associated with fewer adverse events, stronger safety culture, and improved patient outcomes. ^{Reference Bognár, Barach and Johnson4,Reference Neily, Mills and Young-Xu34–Reference Hedges, Johnson and Kobulinsky35}

The consequences of dysfunction extend beyond the patient. Families of children with heart disease depend on the care team for explanation, reassurance, and continuity. Parents often judge quality not only by clinical outcomes but also by whether the team appears aligned, responsive, and trustworthy. When families receive inconsistent messages from different clinicians or observe visible disagreement among team members, confidence in the care process may decline. ^{Reference Walter, Schall and DeWitt12,Reference Medel, Rojas and González36–Reference Ashour, Abou Hashish and Awad37} Communication quality is therefore not simply a relational concern. It is part of safe and reliable care. Dysfunction also affects clinicians themselves. Paediatric cardiac care is emotionally demanding, and persistent communication failures, unresolved conflict, or role strain may intensify stress and contribute to burnout, moral distress, and turnover. ^{Reference Barach, Ahmed and Agarwal38–Reference Lee, Forbes and Lukasiewicz40} Burnout has implications for attentiveness, empathy, retention, and long-term workforce stability. At the organisational level, a reinforcing cycle may emerge in which dysfunction contributes to burnout, and turnover further weakens team familiarity and reliability.

System-based strategies to improve team performance

Improving team performance in paediatric heart care requires a system-based, multifaceted approach. No single intervention can reliably correct entrenched communication patterns, hierarchical barriers, and workflow fragmentation in high-risk clinical environments. Instead, effective programmes typically combine education, process redesign, leadership engagement, and continuous measurement (Figure 3). Simulation-based team training is one of the most widely supported strategies. By allowing teams to rehearse crisis management, communication, role clarity, and leadership in realistic scenarios, simulation can strengthen both technical and nontechnical skills. In paediatric cardiac care, simulation is especially valuable because rare but catastrophic events such as postoperative arrest, severe haemodynamic collapse, airway emergencies, or unexpected surgical complications require coordinated responses that cannot be improvised safely. ^{Reference Hughes, Gregory and Joseph30,Reference Entin, Lai and Barach41–Reference Figueroa, Sepanski, Goldberg and Shah42} Structured debriefing after simulation is equally important because it converts experience into learning, reinforces shared mental models, and uncovers latent system vulnerabilities. Large-scale evidence from surgical safety programmes suggests that team training can be associated with measurable improvements in outcomes, including lower surgical mortality when implemented systematically. ^{Reference Neily, Mills and Young-Xu34}

Figure 3.

System-based strategies to improve teamwork in paediatric heart programmes. Effective improvement requires coordinated interventions in team training, communication systems, leadership and culture, and measurement infrastructure. Together, these strategies support high-reliability team performance. AI = artificial Intelligence; SBAR = Situation, Background, Assessment, Recommendation; TeamSTEPPS = Team Strategies and Tools to Enhance Performance and Patient Safety.

Structured communication tools and standardised handoff protocols are another essential component. Frameworks, such as Situation, Background, Assessment, Recommendation, improve clarity and reduce variation in information exchange, especially during transitions of care. ^{Reference Göbel, Zwart and Hesselink22–Reference Mills, Neily and Dunn23,Reference Foronda, MacWilliams and McArthur43} In paediatric heart programmes, standardised handoffs between the operating room and ICU can help ensure reliable communication of anatomy, intraoperative findings, medication changes, anticipated complications, and immediate priorities. Closed-loop communication, in which information is repeated back and confirmed, is especially valuable during emergencies and in settings with high ambient noise or competing demands. ^{Reference Tan, Zhou and Kelly44–Reference Vermeir, Vandijck and Degroote45} Similarly, pre-procedure briefings and post-procedure debriefings can clarify roles, anticipate challenges, and create a shared understanding of the plan. These tools are most effective when integrated into workflow rather than treated as optional behavioural add-ons.

Multidisciplinary case conferences and structured shared decision-making processes also play a major role in improving team coordination. In many paediatric heart programmes, high-risk cases are reviewed by cardiologists, surgeons, intensivists, anaesthesiologists, imagers, nursing leaders, and other relevant clinicians before intervention. ^{Reference Jacobs, Wernovsky, Cooper and Karl46} Such conferences support shared goals, align expectations, improve contingency planning, and reduce fragmentation of decision-making. They also provide a forum for surfacing disagreement early and translating diverse expertise into a coherent management plan. Cross-training and deliberate attention to team composition may further strengthen performance by improving understanding of adjacent roles and reducing siloed thinking. ^{Reference Willis, Yip, Brown, Buck and Mill47} Teams with balanced experience, complementary expertise, and stable working relationships often function more efficiently because they can anticipate one another’s needs and communicate more effectively during complex procedures. ^{Reference Hallet, Jerath and d’Empaire25,Reference Alten, Cooper and Klugman48}

Interventions should also address the cultural and relational foundations of teamwork. Psychological safety does not arise automatically from skill or experience. It requires leadership behaviours that invite input, acknowledge uncertainty, and respond constructively to concerns. ^{Reference Asante17–Reference Leonard, Graham and Bonacum18} Leaders influence whether frontline clinicians feel safe to speak up when they detect anomalies or potential harm. Team repair and conflict management are similarly important. One structured approach described in the organisational literature is the “Walk in the Woods” method, an interest-based negotiation framework that progresses from clarification of concerns to identification of shared goals, exploration of mutual gains, and agreement on action commitments. ^{Reference Marcus, Dorn and McNulty49} Although not widely studied in paediatric cardiac programmes specifically, such approaches may be useful when repeated conflict or hierarchy-related tension threatens collaboration after difficult cases. Institutions may also benefit from explicit norms for respectful communication and transparent processes for addressing disruptive behaviour.

Beyond training and culture, organisations need methods for measuring whether teamwork is improving. Audit-and-feedback systems, observational teamwork tools, safety culture assessments, and structured handoff evaluations can help paediatric heart programmes move from general endorsement of teamwork to continuous performance measurement. Team Strategies and Tools to Enhance Performance and Patient Safety, and related frameworks provide practical approaches for assessing communication behaviours, leadership, mutual support, and situational awareness in clinical teams. ⁵⁰ Incorporating teamwork indicators into quality dashboards alongside mortality, complications, and length of stay may help leaders evaluate whether interventions are translating into safer care. Finally, emerging technologies, including digital handoff tools, electronic checklists, computerised alerts, and artificial intelligence- supported analytics, may enhance shared situational awareness and reduce cognitive overload. Artificial intelligence systems may help identify deterioration earlier, highlight omitted tasks, or synthesise complex trends from haemodynamics, laboratory data, and imaging. However, such tools should be viewed as supports for human teamwork, not substitutes for it. Poorly designed systems can create alert fatigue, obscure accountability, or amplify bias if trained on inequitable or incomplete data. The most promising role for technology is to improve information reliability, strengthen decision support, and make team communication more consistent. ^{Reference Howick, Bennett-Weston and Solomon51–Reference Shaker, Oppenheimer and Verdi53}