Leadership delegation, team efficacy and resilience in critical care: a simulation-based study

Objective: To quantitatively assess leadership delegation in expert critical care teams during simulated emergency scenarios, and to explore its association with team efficacy and resilience. Design: Multicentre, prospective observational study using high-fidelity simulation. Three critical care scenarios of increased difficulty were developed, each incorporating carefully calibrated expected and disruptive events. Setting: Five university-affiliated simulation centres in France. Participants: 30 interprofessional teams (150 participants), each composed of a senior physician, resident, nurse, healthcare assistant and medical student, all having worked together clinically. Main outcome measures: Occurrence and characteristics of leadership delegation following events; team performance as evaluated by external experts; self-reported team member satisfaction, engagement and cohesion; statistical associations using sparse Partial Least Squares and unsupervised clustering. Results Delegation occurred less frequently with increased scenario difficulty (p=0.003 for comparison between scenarios). In contrast, delegations initiated by team members other than the senior physician were more frequent in scenarios with a higher number of disruptive events (p=0.004). Delegation was moderately correlated with resilience parameters (team satisfaction, engagement and cohesion parameters, typically ρ>0.25) but showed no association with simulated patient survival. Clustering revealed a mismatch in some team members between high satisfaction and low performance. Conclusions: Delegation in emergency teams was associated with team resilience rather than with clinical performance. Disruptive events led to leadership coming from other team members than the leaders.