Cognitive versatility and adaptation to fluid participation in hospital emergency department teams

Effective organizational coordination requires solving two intertwined problems: dividing labor and integrating effort. The Carnegie School's work on bounded rationality, routine-based behavior, and learning has led to role-based structures and standard operating procedures to address these issues. However, the increasing fluidity of team structures, characterized by constant shifts in composition and skill sets (fluid participation), challenges traditional coordination mechanisms. Fluid participation can lead to disconnected or intersecting role sets, affecting task delegation and coordination. This research explores the hypothesis that a disconnected role set constrains flexible coordination, while cognitive versatility in a team's strategically central member (e.g., the attending physician) may mitigate this constraint. The study uses data from a hospital Emergency Department to assess team effectiveness based on patient length of stay and handoffs, examining the role of role set configuration and attending physician's cognitive versatility.

The Carnegie School's emphasis on 'the organization of attention' and bounded rationality is crucial in understanding organizational choice. Cohen et al.'s garbage can model highlights 'fluid participation' as a key characteristic of organized anarchies, impacting decision-making by limiting attention. This concept is increasingly relevant to contemporary teamwork, where fluid participation is common due to labor shortages, scheduling conflicts, and varying skill sets. Existing research on fluid participation in teams emphasizes the importance of structured role systems to guide attention and facilitate coordination. However, the constantly changing skillset configurations challenge the adequacy of even structured role sets, leading to the investigation of individual characteristics like cognitive versatility as potential mitigating factors. Cognitive versatility, the ability to flexibly shift between cognitive styles, offers individual adaptability and is found to benefit team information processing and performance. The study further integrates research on team composition and the outsized influence of strategically central team members, hypothesizing that cognitively versatile core members can improve coordination in fluid settings, particularly with less-connected role sets.

Data were collected from a 12-bed emergency department over 5 months in 2011. The data include hospital scheduling records, patient health records, and surveys completed by attending physicians. Teams were defined as the set of providers working together during 12-hour shifts, encompassing 342 teams in total. A disconnected role set was defined as the absence of a nurse practitioner (NP), resulting in less task overlap between roles. The attending physician was considered the strategically central core member. Cognitive style versatility of the attending physician was measured using the Object-Spatial Imagery and Verbal Questionnaire (OSIVQ), calculating the standard deviation of scores across three cognitive styles (object visualization, spatial visualization, and verbalization). Team effectiveness was measured using average adjusted length of stay (ALOS) and the number of patients handed off to the next shift (lower scores indicating greater efficiency). Control variables included team member attributes (conscientiousness, social perceptiveness, experience, cognitive style strength), team-level factors (familiarity, patient carryover, admissions, number of nurses, support staff presence, case typicality), and fixed effects (weekday, month, night shift). Mixed effects models were used to analyze the data, accounting for the non-independence of teams due to overlapping members. Robustness checks included additional models with fixed effects for physicians and cluster-robust standard errors, as well as sensitivity analyses varying the time window for familiarity measure and coarsened exact matching to balance the sample regarding patient load and number of nurses.

The analysis revealed that core member (attending physician) cognitive versatility was positively associated with team effectiveness (fewer handoffs, shorter ALOS). Teams with a disconnected role set (lacking an NP) exhibited lower effectiveness (more handoffs, longer ALOS). Crucially, the negative relationship between a disconnected role set and team effectiveness was significantly mitigated by the attending physician's cognitive versatility. This moderating effect remained robust even after controlling for other individual and team-level factors. Further, analyses demonstrated that the benefits of core member cognitive versatility were particularly pronounced in teams with disconnected role sets; in such teams, a higher level of cognitive versatility in the physician was associated with a reduction of approximately one and a half fewer patients handed off per shift. The observed effects were robust to the inclusion of multiple control variables such as team familiarity, physician's years of experience, social perceptiveness, and conscientiousness. Moreover, the findings continued to hold when using a shortened lookback window for the familiarity measure and after employing coarsened exact matching to balance the sample on patient load and number of nurses. This ruled out alternative explanations such as the correlation between the absence of an NP and lighter workloads.

The findings support the hypotheses, indicating that cognitive versatility in strategically core team members is a valuable asset in navigating the challenges of fluid participation, especially when structural flexibility is limited by a disconnected role set. The results extend the Carnegie School's work by highlighting the significance of individual attributes alongside organizational structures in enabling effective coordination in dynamic settings. The moderating effect of cognitive versatility suggests that the capacity for flexible thinking and adaptation can compensate for structural limitations. The study’s focus on less-connected role sets resulting from planned role configurations (e.g., scheduled absence of NPs) could be extended to explore unplanned disruptions, such as unexpected absences or scheduling conflicts. The study also contributes to research on intrapersonal diversity, showing that cognitive versatility, a form of within-person diversity, can facilitate adaptation and mitigate negative effects of disconnected role sets. Future research could delve into the mechanisms by which cognitive versatility enhances team coordination.

This study demonstrates the importance of cognitive versatility in strategically central team members for mitigating the negative impacts of fluid participation and disconnected role sets in dynamic team settings like hospital emergency departments. The results underscore the need to consider both organizational structures and individual attributes when designing and managing teams. Future research could focus on investigating causal mechanisms, exploring the effects of unplanned role set disruptions, and further examining the interplay between various individual traits in fluid teams.

The study's correlational nature limits causal inferences. While control variables were included, the possibility of unmeasured confounding factors remains. Future research should employ experimental designs to establish causality. The study's focus on a specific healthcare setting may limit generalizability to other contexts. Further research is needed to explore the applicability of these findings to various organizational settings and team types. The study also lacks direct observation of coordination behaviors, limiting a deeper understanding of the mechanisms by which cognitive versatility improves team efficiency.