The two ED sections differed greatly in the degree of performed teamwork behaviors. They also differed in the behavior change interventions that were used. At the Section of Internal Medicine, where teamwork was implemented to a higher degree, BCIs focusing on clarifying Direction and providing Opportunity to perform teamwork behaviors were primarily used. These also had motivating functions. Motivational BCIs played an important but temporary role during the initial implementation. Experiences of positive results of teamwork, e.g. task-related feedback, were more important for long-term motivation and maintained behavior change. The findings are discussed in more detail below, together with reflection on the usefulness of the DCOM® model.
The two sections used different BCIs when implementing teamwork. The functional analysis of the BCIs showed that the enabling dimensions Direction and Opportunity were the most important in supporting the implementation of teamwork at the Section of Internal Medicine. During program installation, directional BCIs involved influential messengers at different managerial levels, which has been highlighted as essential in prior studies as well [50, 51]. The intensity of directional BCIs increased substantially during initial implementation. This was important for a number of reasons. For instance, the physicians working at the Section of Internal Medicine changed regularly and were not familiar with all the routines. In addition, teamwork was systematically adapted during the installation phase, and thus the adjustments needed to be communicated to staff. The directional BCIs also entailed management giving correctional feedback on team behaviors. This corrective action offered few options for alternative behaviors. The Section of General Surgery used fewer influential messengers when introducing teamwork. Upper management was hardly involved, and did not provide Direction or create Opportunity. Directional BCIs were not systematically repeated during initial implementation, and the content of the directional BCIs was not congruent; i.e. staff received different, often conflicting, directions. This resulted in a wide range of individual interpretations of teamwork behaviors. In addition, staff did not agree on teamwork as a means to achieve department goals. Prior studies emphasize the importance of creating positive attitudes and anticipation regarding the results of change [52, 53]. From a theoretical stand point this created an initial motivation to engage in key behaviors by increasing valence, i.e. how you value the result of a change. From a functional perspective, real-life experience of consequences is the strongest determinant of behavior change , suggesting that anticipated consequences are important during the initial stage of implementation but that the effect diminishes as it is replaced by real-life experience of behavioral consequences. This is also known as operant conditioning and describes the well documented psychological process whereby the effect of antecedents, i.e. anticipated consequences, on behavior is altered as a function of real-life consequences . Social cognitive research also supports this in that it emphasizes experience as the strongest determinant of self-efficacy , an important predictor of behavior change. Managerial consequences, such as feedback and managers showing interest, are also known to influence staff behavior [55, 56]. In all, this suggests that directional BCIs have an important but short-term motivational influence on behavior change, and need to be supplemented with motivational BCIs to create sustainable change.
The Competence dimension was not described as important for implementing teamwork. However, staff at the Section of Internal Medicine most certainly developed skills in terms of learning the new work processes and roles during the first months of on-the-job training. That is, the low importance of Competence does not mean that no skills were developed. Rather, it might reflect that (1) the brief training focused on interpersonal competence that staff experienced that they already had, and (2) the learning of new work processes and roles was perceived as a natural part of adapting to the new work process.
Opportunity, i.e. the tools, resources and processes provided by the organization, at the Section of Internal Medicine consisted of two parts. The first involved changes in staff resources and room allocations based on a pre-implementation analysis of barriers, and was performed mainly during program installation. The second part took place during initial implementation, and involved ongoing problem-solving. The complexity of the organization made it difficult to foresee all obstacles. This meant that creating Opportunity before implementation start was important, but not sufficient, for handling barriers to performance. With the functional perspective of ABA, the organizational barriers initially provided punishing consequences in response to key teamwork behaviors and thereby decreased the probability that the behaviors would be repeated [27–29]. The punishing consequences included, for instance, a slower work pace and frustration with practical barriers. With the absence of systematic problem-solving at the Section of General Surgery, staff did not deal with the barriers, and as punishing consequences accumulated staff reverted to the traditional work process as a way to avoid the punishing consequences associated with teamwork. The functional analysis of behavioral consequences suggests a way to understand the underlying mechanisms of behavior change and how the short-term adoption, but long-term desertion, of key behaviors might be understood. This is an important contribution to understanding sustainable implementation, which has been cited as an area in need of further research . In summary, the ongoing provision of problem-solving activities at the Section of Internal Medicine was important in enabling teamwork behaviors as it changed important factors in the organizational context. Thus, problem-solving was used to improve the fit between the intervention and the organizational context, thereby increasing the probability of reinforcing consequences. This is the core of tailored interventions . However, tailored interventions often focus on the pre-installation identification of barriers. The findings from this study suggest that this may not be enough in interventions involving complex change. Instead, an ongoing identification and handling of barriers to change may be necessary. This type of continuous improvement is the core of many improvement models, such as Kaizen  and PDSA . However, it seems that ongoing problem-solving needs to be combined with concurrent directional BCIs that communicate adaptations to the program.
Staff motivation to change behavior at the Section of Internal Medicine was primarily a function of task-generated feedback from engaging in teamwork behaviors . As teamwork was enabled and barriers to performance were removed, staff experienced both fewer punishing consequences and more positive and valued consequences when engaging in teamwork behaviors. That is, teamwork behavior was conditioned by real-life consequences. This means that Motivation was an implicit result of enabling BCIs in combination with staff valuing the task-generated feedback that came from engaging in teamwork behaviors. Task-related feedback involving direct response from multiple sources, including patients, has previously been shown to be related to high work motivation . At the Section of General Surgery staff did not experience positive task-generated feedback, as teamwork behaviors were not sufficiently enabled and sustained. Overall, task-generated feedback, which comes naturally as a response to behavior, is emphasized as an important motivational factor in many motivational theories [61–65]. It is intrinsic rather than extrinsic in character, and is thereby considered to have a stronger motivational effect [62, 66]. This case is an example of how task-related feedback is delayed and not fully distributed during the first months of implementation. Basically, this was because it took time to get the new work practices to function well enough to create positive task-related feedback. However, management feedback and small daily improvements were important motivational BCIs during the two first months of implementation, and bridged the motivational gap before task-related feedback was fully enabled. It is known that managerial feedback can increase motivation [55, 60], and that managerial activities, e.g. feedback, problem-solving etc., are especially important for new teams . Thus, this study suggests that controllable BCIs, such as management feedback, encouragement and problem-solving, may have a more important motivational function during initial implementation but less so later, given that the change involves task-generated feedback. Another possible explanation for motivation during the first months of implementation is that the experience of small daily improvements had a motivating effect during this period. This is in line with operant psychology  and theories on work motivation, such as control theory and social cognitive theory [54, 68].
Practically, these findings describe how organizations can optimize the implementation of new ways of working by choosing BCIs based on which function (Direction, Opportunity, Competence or Motivation) is the most important.
At the Section of Internal Medicine, the fidelity to the teamwork intervention was described by the staff as sufficient despite the fact that the number of teamwork behaviors performed in each patient case varied. This may reflect that not all team behaviors were applicable to all patients at all times, such as uncomplicated cases that only required attention from the physician. It also reflects that some key behaviors are contingent on specific events; for example, the teamwork behavior Communicating decision to change plan can only take place once there has been a change in plans. This is in line with a prior study showing how some intervention components need to be customized to each patient , and highlights the need to allow local adaptation. The Replicating Effective Programs (REP) framework suggests that the core elements of an intervention should be standardized, but that the mechanism by which they are operationalized can be changed to allow flexibility in implementation . In other words, the judgment of which components are to be delivered to each patient should be made by staff as long as this is in line with the overall aim, i.e. Direction. This suggests that the measurement of actual behavior change when implementing methods consisting of multiple components should carefully consider which behaviors are necessary for determining fidelity levels.
This study involved two sections that implemented the same work processes in very similar settings . The main differences in the implementation procedures were different management, different physicians and start-up five months apart. This gives us favorable conditions for comparing the impact of the different behavior change interventions used, in line with comparative case study methodology . External validity of the study might be limited due to the Swedish model depending on physicians on call rather than full-time specialists in emergency care. This could have an effect on the importance of the Direction dimension. On the other hand, external validity is strengthened as the BCIs used are common techniques when implementing teamwork in other settings. Thus, the function of the dimensions should be relevant for other organizations. Rather than developing a new model, this study is based on basic psychological science and well-established models for behavior change. Using established theories and models contributes to the accumulation of knowledge.
A number of validity criteria for trustworthiness need to be highlighted and discussed . To show credibility, well established qualitative methods were used and the whole research team participated in the data analysis. The study is part of a larger longitudinal intervention project; thus, the researchers were familiar with the context and the staff. The sampling procedure was purposive, using informants with a central role in the implementation. The triangulation, using observations, interviews and documentation, was useful in establishing confidence in the truth of the data. Analysis of qualitative data was performed by researchers with at least five years’ experience with the models used, which is considered a strength as the theory-driven approach used is regarded as especially sensitive to the experience of the researcher . Credibility was limited by the number of interviews. Also, the complex ED environment with a high number of staff members (some temporary) as well as high tempo and workload sometimes made observation challenging. This was handled partly by using many observers, who continuously discussed their observations, and through the large number of observations. Regarding dependability, the research design is well documented and the team regularly reflected upon the process. To address transferability to other settings or groups, awareness of the clinical context and culture is necessary. Some of the BCIs’ functions, e.g. problem-solving, might be more important in complex contexts.
Implications for practice
Teamwork is a promising intervention to improve health care. However, in practice, both teamwork and its implementation may look very different in different settings. The most important lesson from this study is not a specific teamwork intervention. Rather, this study highlights how teamwork can be implemented and suggests that clear Direction (i.e. engaged management that is specific regarding both why and how teamwork should be performed, alignment between teamwork and other processes and initiatives) and allocation of resources for ongoing problem-solving and adaptation are important ingredients for effective implementation of teamwork, and possibly other complex changes. This is especially important in organizations with a rapidly and continuously changing context. Also, when implementing interventions that are not immediately rewarding for staff, it is important that management or a change team actively support and motivate the staff.