Emotional Turmoil and Time Constraints Decrease the Ability of Team Members to Communicate Effectively and Make Decisions

Objective Decision making in stressful environments transitions from goal-directed behavior to habitual behavior. Restructured dendritic volume and density in the sensorimotor corticostriatal circuits following exposure to chronic and acute stressors leads to altered cognition in mammals of various sizes. Routine system one thinking replaces dynamic system two thinking with repetitive stress, leading to automatic decision making, especially when confronted with abnormal scenarios or distracting elements. Additionally, perceived fear of invalidity reduces active decision making. Professionals such as critical care air medical providers who work in environments with known emotional and cognitive distractions must learn techniques and strategies to retain creative decision making and purposeful communication when exposed to stressors. The absence of dynamic decision making and effective communication lead to poor patient outcomes and unsafe environments. The objective of this meta-analysis is to determine coping mechanisms and education strategies proven to recruit creating clinical thinking in the presence of known stressors. Methods This study utilized a meta-analysis of current literature of stress performance, cognitive appraisal, team dynamics, and communication. The researcher surveyed scientific peer-reviewed articles covering neurophysiology, brain mechanics, decision making, conflict theory, stress response, and effective communication. Results Emotional turmoil and time constraints decrease the ability of team members to communicate effectively and make decisions. Conflict, threat, crisis, and time pressure are correlated with poor decision making and the relationship is amplified directly by intensity of the experience. Cognitive and affective biases narrow anticipated outcomes and result in increased focus but an inability to consider externalities. Innovation is based on novel ideas, which is dependent upon the ability to weigh the benefits and limitations of action outside the current strategy. Medical decision making among teams that did not include metacognition, reflection, or mindfulness resulted in adherence to the initial plan of action despite cues to alter the care plan or re-evaluate priorities and effectiveness of interventions. The lack of communication accounted for 80% of serious medical errors such as diagnostic failures and led to interpersonal strain among team members following the event. Divergent structural reorganization of neural circuitry following the experience of stressors led to hypertrophy of corticostriatal circuits through the sensorimotor striatum. Performance during times of stress is not only a cognitive function, but also a result of anatomic reorganization toward habitual strategies. Habitual behavior increased speed and performance in predictable scenarios but had obvious limitations in complex environments. Subjects were unable to shift from habitual strategies to goal-directed strategies when under stress, however findings from the cognitive sciences may prove beneficial to medical sciences and clinical decision-making. Cognitive flexibility, recognition of changes, and generation of novel solutions can be trained into the individual and the group. Recognition of the need for unique ideas is the first step in developing divergent thinking capabilities and creative thought. Abductive reasoning and purposeful communication were correlated with better decision-making and innovation. The OODA Loop describes one method of contextualizing a decision and includes the steps of observe, orient, decide, and act. The context and consequences of the decision are considered and generate a cognitive loop in which the mental process is fluid rather than static. This prevents unilateral dedication to a poor decision made early on and facilitates flexibility. OODA Loops are enhanced with verbal metacognition, which describes members of the team thinking out loud rather than internalizing their personal thought process. Conclusions Extreme uncertainty defies the predictive nature of Bayesian probability and the accuracy of normal predictive patterns. Normal algorithms utilized to come to conclusions are inaccurate in dynamic environments and lead to clinical errors in medical treatment. Critical care air medical providers operate in environments that are emotionally intense and time sensitive, making the need for effective communication and appropriate decision making a requirement for providing patient care. Simple steps such as establishing priorities in treatment plans or utilizing check lists generate shared mental models of treatment plans but remain static if not re-visited. Metacognition involves the verbal communication of thoughts, plans, and considerations and facilitates a discussion among providers that leads to creative thinking and fewer mistakes. Teams in the air medical environment are often small, however communication remains a necessary ingredient for cooperation and patient advocacy. It is unlikely to establish shared mental models and flow states without verbal expressions of goals and plans. In this way, communication and decision-making work synergistically. Metacognition provides the vehicle by which detrimental habitual behaviors are identified and corrected. Speaking a plan out loud recruits additional neural pathways and facilitates recognition of mistakes. When members of a team are open to expression and reception of a message, those team members critically analyze the information and consider divergent views as needed in real time. Vocalization in times of stress is not a natural talent for most individuals; it is a skill that can be developed with purpose and training. Metacognition can be established as a habitual behavior with training and then becomes the defacto process even in the presence of excessive stressors. Practicing metacognition during simulations breaks the cycle of stressful decision-making by forming communication as a habitual behavior. Managers and educators can encourage verbal communication as a skill through simulation followed by group video debriefing. Modeling the process of thinking out loud advances problem-solving strategies and team dynamics, encourages interpersonal communication, establishes healthy cognitive re-evaluation of plans in unpredictable environments. Improved communication decreases decision-making mistakes and improves patient care. Verbally fluent and mindful clinicians are able to express plans, identify areas of deficiency, correct mistakes in a timely manner, and communicate a sense of control and compassion to patients. 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8