Team Emergency Assessment Measure (TEAM)

1. Abstract

The Team Emergency Assessment Measure (TEAM) is an internationally validated, clinician-rated observational psychometric instrument designed to evaluate the non-technical skills and behavioral teamwork dynamics of emergency medical resuscitation and trauma teams. Originating from critical gaps in crisis management assessment within high-acuity acute care, the instrument addresses the vital cognitive, behavioral, and interpersonal dimensions that dictate clinical survival during cardiopulmonary arrest and severe physiological destabilization. The tool comprises 12 items structured across three core behavioral domains: Leadership (items 1–2), Team Work (items 3–9), and Task Management (items 10–11), alongside an overarching single-item Global Rating (item 12) measuring overall team performance.

Items 1 through 11 are scored on an anchored five-point frequency scale ranging from 0 (Never/Hardly ever) to 4 (Always/Nearly always), yielding a composite non-technical performance score between 0 and 44, while item 12 employs an independent global visual rating scale ranging from 1 to 10. Psychometric evaluations demonstrate exceptional content validity (total Content Validity Index = 0.96) and robust internal consistency (Cronbach’s alpha ranging from α = 0.89 to 0.97 across multiple international cohorts). Exploratory and confirmatory factor analyses consistently substantiate a dominant unidimensional teamwork construct accounting for substantial variance, alongside distinct, coherent empirical sub-dimensions. The instrument demonstrates strong concurrent validity through high correlations between the summated 11-item score and the global performance scale (rho = 0.95, p < 0.01), with acceptable inter-rater reliability (κ = 0.55 to 0.80) and test-retest stability (κ = 0.53). Widely implemented in high-fidelity simulation training, continuing interprofessional education, and authentic resuscitation room auditing, the TEAM instrument provides a rigorous, standardized foundation for objective performance measurement, debriefing, and translational clinical research.

2. Keywords

Team Emergency Assessment Measure, non-technical skills, resuscitation performance, clinical leadership, crisis resource management, situational awareness, interprofessional simulation, patient safety, trauma team evaluation, medical debriefing, psychometric validation, task management.

3. Authors

The Team Emergency Assessment Measure (TEAM) was developed, standardized, and psychometrically validated by a multi-institutional consortium of clinical educators, nursing scientists, and medical simulation researchers in Australia. The primary investigative panel includes:

• Simon Cooper, PhD, RN, FCHSM – Professor of Nursing, School of Nursing and Healthcare Professions, Federation University Australia (formerly Monash University), Victoria, Australia. Focus area: Resuscitation education, non-technical skills acquisition, patient safety.
• Robyn Cant, PhD, MEd – Senior Research Fellow, School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia. Focus area: Simulation pedagogies, quantitative psychometrics, clinical competencies.
• Joanne Porter, PhD, RN – Associate Professor, Collaborative Evaluation and Research Centre (CERC), Federation University Australia, Victoria, Australia. Focus area: Emergency nursing, resuscitation systems, clinical teamwork.
• Kenneth Sellick, PhD, RN – Adjunct Associate Professor, School of Nursing and Midwifery, Monash University, Victoria, Australia. Focus area: Psychometric modeling, measurement theory, health assessment design.
• Gail Somers, MBBS, PhD – Senior Lecturer and Medical Educator, School of Rural Health, Monash University, Victoria, Australia. Focus area: Medical education, acute care team behaviors.
• Leigh Kinsman, PhD, RN – Professor of Nursing, University of Newcastle and Priority Research Centre for Generational Health and Ageing, New South Wales, Australia. Focus area: Clinical pathway optimization, evidence-based acute care.
• Debra Nestel, PhD, FAcadMEd – Professor of Simulation Education in Healthcare, Monash University, and Professor of Surgical Education, Department of Surgery, University of Melbourne, Victoria, Australia. Focus area: Simulated patient methodologies, non-technical skills evaluation, debriefing architectures.

Institutional Correspondence: Inquiries regarding the development, administrative protocols, and translational research of the TEAM instrument are directed via Federation University Australia and Monash University clinical simulation laboratories.

4. Purpose

The primary purpose of the Team Emergency Assessment Measure (TEAM) is to furnish healthcare educators, resuscitation researchers, and clinical supervisors with a psychometrically robust, feasible, and standardized observational instrument to appraise non-technical performance during dynamic, time-critical medical crises. Medical emergencies—including sudden cardiac arrest, polytrauma presentations, acute respiratory failure, and perioperative collapse—unfold in volatile, ambiguous, and high-stakes operational environments. Decades of epidemiological root-cause analyses have demonstrated that preventable morbidity and mortality in these contexts stem disproportionately not from deficits in clinical or pharmacologic knowledge, but rather from latent failures in communication, leadership ambiguity, poor coordination, delayed prioritization, and collapsed situational awareness.

Prior to the introduction of the TEAM instrument, validated behavioral markers for non-technical skills existed primarily for closed-loop environments such as the operating theater (e.g., the Non-Technical Skills for Surgeons [NOTSS] tool and the Anaesthetists’ Non-Technical Skills [ANTS] framework). These existing frameworks failed to capture the fluid, ad-hoc, and multiprofessional nature of emergency medical teams (EMTs), Rapid Response Teams (RRTs), and resuscitation code teams. Code teams frequently coalesce spontaneously, drawing together physicians, critical care nurses, respiratory therapists, and allied staff who have never previously rehearsed or collaborated as a unit. The TEAM tool was specifically designed to capture these interdisciplinary mechanics, functioning simultaneously as an objective evaluative metric and a structured debriefing template.

In clinical practice, the tool is utilized within quality improvement registries, real-time audio-visual resuscitation recording reviews, and in situ clinical audits to evaluate baseline institutional response patterns, uncover latent hospital system threats, and track institutional safety culture over time. In educational and simulation-based healthcare training, the TEAM instrument bridges didactic learning and clinical execution. By providing precise behavioral rubrics across specific operational domains, it enables faculty to deliver immediate, objective, criterion-referenced feedback during post-event debriefings, thereby transforming subjective critiques into measurable performance targets and reinforcing sustained behavioral change.

5. Psychological Construct

The psychological construct underlying the TEAM instrument is Interprofessional Non-Technical Team Performance in Dynamic Clinical Environments. Non-technical skills refer to the cognitive, behavioral, and social resources that complement technical expertise, directly moderating the safety, efficiency, and physiological outcomes of clinical interventions. The TEAM instrument deconstructs this overarching construct into three operationalized behavioral domains, culminating in an integrated global appraisal:

Leadership

The leadership subscale operationalizes the cognitive and interpersonal behaviors executed by the designated or emerging resuscitation leader to establish situational command and structural order. Effective clinical leadership during crises requires balancing authoritative tactical direction with open receptive awareness. Item 1 (The team leader let the team know what was expected of them through direction and command) captures role assignment, direct verbal instruction, clarity of role boundaries, and assertive guidance. Item 2 (The team leader maintained a global perspective) measures metacognitive situational monitoring—the capacity of the leader to remain cognitively detached from hands-on procedural tasks (e.g., intubation, vascular cannulation, chest compressions) in order to preserve a macroscopic cognitive map of the emergency trajectory, monitor environmental variables, allocate cognitive bandwidth, and supervise delegation.

Team Work

The teamwork subscale constitutes the behavioral core of the instrument (items 3 to 9), assessing distributed social and cognitive interactions across both the leader and team members as a cohesive sociotechnical unit:

• Interpersonal Communication (Item 3): Evaluates closed-loop communication cycles, verbal transmission clarity, active listening, non-verbal coordination, and real-time medical record annotation under severe acoustic and cognitive interference.
• Task Coordination and Temporal Pacing (Item 4): Assesses collaborative synchronization, avoidance of procedural bottlenecks, dynamic load-sharing, and the fluid completion of algorithmic interventions (e.g., early defibrillation, rapid vascular access) within critical physiological windows.
• Composure, Stress Coping, and Affective Regulation (Item 5): Examines psychological resilience, the containment of escalating panic, controlled tone of voice, professional equilibrium, and the immediate resolution of interpersonal friction under extreme clinical duress.
• Team Morale and Collective Efficacy (Item 6): Measures shared psychological safety, reciprocal mutual support, collective confidence, focused optimism, and persistent determination to stabilize the deteriorating patient.
• Adaptive Capacity and Cognitive Flexibility (Item 7): Measures dynamic adaptation to unexpected physiological deterioration, unheralded anatomical difficulties (e.g., failed airways), rapid personnel transitions, or sudden protocol modifications.
• Situational Monitoring and Environmental Reassessment (Item 8): Captures cross-monitoring, redundant surveillance of physiological monitors, vocalized reassessments following medication delivery or defibrillation, and active error-checking across team boundaries.
• Anticipatory Planning and Feedforward Cognition (Item 9): Measures the prospective cognitive preparation for downstream clinical trajectories (e.g., advanced airway preparation, drawing up second-line vasopressors, readying the automated chest compression device before patient transit).

Task Management

Task management encompasses the structural and procedural execution of clinical crisis protocols. Item 10 (The team prioritised tasks) assesses cognitive triage, differentiating life-threatening physiological insults from secondary technical details. Item 11 (The team followed approved standards and guidelines) evaluates fidelity to established clinical practice parameters (e.g., Advanced Cardiac Life Support [ACLS] algorithms), while explicitly accommodating legitimate, calibrated deviations dictated by idiosyncratic patient presentations.

Global Non-Technical Performance

Item 12 functions as a holistic evaluative gestalt (measured on a 1-to-10 continuum), enabling experienced clinical raters to synthesize unquantifiable systemic interactions, emotional resonance, and emergent properties that may elude atomized behavioral point scoring.

6. Theoretical Framework

The Team Emergency Assessment Measure is theoretically rooted in Crew Resource Management (CRM), modern Cognitive Psychology, and Systems Safety Engineering. The primary lineage derives from aviation human factors research pioneered by Helmreich and colleagues, who formulated the Threat and Error Management (TEM) model. TEM posits that human error is inevitable in complex, sociotechnical environments; therefore, safety is not defined by the absolute absence of errors, but rather by the presence of cognitive and interpersonal countermeasures designed to detect, trap, and mitigate threats before they culminate in catastrophic harm.

Secondly, the instrument is anchored in Shared Mental Model (SMM) Theory, extensively articulated by Cannon-Bowers and Salas. SMM theory asserts that high-performing teams operating under conditions of time pressure, noise, and information overload rely on compatible, distributed cognitive representations of task requirements, equipment interfaces, and team member capabilities. In an emergency resuscitation, a shared mental model enables individual team members to anticipate each other’s informational and tactical needs without explicit, time-consuming verbal coordination. Items assessing anticipatory actions (Item 9), collective adaptability (Item 7), and global situational perspective (Item 2) operationalize the degree to which an emergency team has converged upon a unified, functioning mental model.

Furthermore, the conceptualization of situational awareness within TEAM draws directly upon Endsley’s Three-Tier Model of Situation Awareness:

1. Level 1: Perception – detecting critical physiological cues, alarms, and monitor traces (Item 8: situation monitoring).
2. Level 2: Comprehension – integrating disparate sensory data to recognize acute diagnostic syndromes, such as tension pneumothorax or refractory ventricular fibrillation (Item 10: task prioritization).
3. Level 3: Projection – forecasting the future clinical trajectory and preparing downstream interventions (Item 9: anticipating potential actions).

Lastly, the tool integrates modern organizational theories of Psychological Safety (Edmondson, 1999). Resuscitation teams must function in high-acuity environments where subordinate team members (such as junior nurses or students) feel structurally empowered to voice critical safety observations, challenge erroneous drug calculations, and suggest alternative diagnoses without fear of hierarchical humiliation or retribution. This dynamic is directly assessed through the combined evaluation of communicative clarity (Item 3), emotional composure (Item 5), and team morale (Item 6).

7. Validity

The validity of the Team Emergency Assessment Measure has been comprehensively corroborated across international psychometric investigations, spanning simulation centers and real-world clinical resuscitation units.

Content and Face Validity

During the foundational development by Cooper and colleagues (2010), an extensive systematic review of healthcare and industrial teamwork literature yielded an initial behavioral item pool. This draft was iteratively evaluated by an international panel of seven independent experts in resuscitation medicine, acute care nursing, and medical education. The expert review established a total Content Validity Index (CVI) of 0.96, signifying near-universal consensus regarding the relevance, clarity, and representativeness of the items. Raters confirmed that the 11 specific behavioral markers precisely delineate observable, non-technical performance dimensions required during resuscitation crises.

Construct Validity

Construct validity was initially demonstrated across 56 video-recorded hospital and simulated resuscitation events involving senior medical and nursing personnel, followed by 15 real-time clinical simulations. Construct validity was corroborated by the tool’s sensitivity in differentiating performance across distinct levels of clinical experience: senior, highly trained interprofessional teams systematically outperformed junior and novice cohorts across all subscale parameters. Confirmatory studies internationally (e.g., validation studies in French, Portuguese, Spanish, and Mandarin acute care settings) have continually confirmed that the TEAM score discriminates effectively between well-coordinated teams and dysfunctional units characterized by task paralysis, communicative ambiguity, and cognitive fixation.

Concurrent and Criterion Validity

Concurrent validity was rigorously established by correlating the summated 11-item score (0–44) against the independent 1-to-10 Global Rating score (Item 12). Cooper et al. (2010) reported a Spearman’s rank correlation coefficient of rho = 0.95 (p < 0.01), demonstrating virtually complete linear convergence between granular behavioral marker tracking and holistic expert evaluation. Subsequent international studies have reported concurrent validity coefficients consistently exceeding rho = 0.85 when benchmarked against parallel behavioral rating instruments, including the Anaesthetists’ Non-Technical Skills (ANTS) score, the Ottawa Crisis Resource Management Global Rating Scale, and the Clinical Performance Tool.

Discriminant Validity

The scale effectively distinguishes non-technical performance from isolated technical skills proficiency. Studies evaluating parallel technical metrics (e.g., exact time to initial chest compression, hands-off compression fraction, or speed of successful endotracheal tube placement) demonstrate low to moderate correlations (r = 0.22 to 0.41) with TEAM scores, confirming that while non-technical skills facilitate prompt procedural execution, the TEAM instrument uniquely measures behavioral, communicative, and cognitive constructs rather than psychomotor manual dexterity.

8. Reliability

The reliability of the TEAM instrument has been established across multiple independent psychometric investigations, demonstrating high internal consistency, acceptable inter-rater concordance, and robust test-retest reproducibility.

Internal Consistency

In the foundational development study by Cooper et al. (2010), the instrument’s internal consistency, calculated across all 11 core items, yielded a Cronbach’s alpha of α = 0.89, reflecting strong scale coherence without excessive item redundancy. Subsequent cross-cultural adaptations and large-scale clinical trials have demonstrated even higher internal consistency estimates:

• Cant et al. (2016) reported a Cronbach’s alpha of α = 0.97 across a nationwide multi-site simulation study comprising over 100 interprofessional emergency scenarios.
• Cross-cultural validation studies, including the European Portuguese translation by Márcio et al. (α = 0.93) and the French emergency validation study (α = 0.91), have consistently verified the high internal reliability of the 11-item scale across diverse healthcare delivery systems.

Inter-Rater Reliability

Inter-rater reliability was initially assessed during the video analysis of 56 simulated resuscitation scenarios scored independently by pairs of trained clinical observers. Using Cohen’s kappa and intra-class correlation coefficients (ICC):

• The original investigation identified an overall kappa of κ = 0.55, classified as “fair to moderate” agreement under strict categorical concordance frameworks.
• Subsequent studies that incorporated structured, standardized rater calibration training reported improved inter-rater reliability, with two-way mixed-effects ICCs ranging from ICC = 0.68 to 0.86 for total scores, and weighted kappa values for individual items ranging from κ_w = 0.61 to 0.79.
• Discrepancies between raters occur primarily in the subjective interpretation of subtle behavioral nuances within Item 5 (composure) and Item 6 (morale), whereas Item 1 (leadership direction) and Item 10 (task prioritization) consistently exhibit the highest inter-rater agreement (κ > 0.80).

Test-Retest Reliability and Stability

Retest reliability, evaluated through delayed blind re-scoring of identical video recordings at intervals between two and four weeks, demonstrated a kappa coefficient of κ = 0.53 in initial feasibility trials. When continuous scoring frameworks (total sum 0–44) were analyzed with Intraclass Correlation Coefficients, temporal stability yielded values of ICC = 0.82 to 0.91, indicating high rating reproducibility when observational evaluations are performed by experienced, calibrated clinical examiners.

9. Factor Analysis

The structural dimensionality of the TEAM instrument has been scrutinized through both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) to determine whether the instrument measures a single global teamwork dimension or distinct, correlated sub-dimensions.

Exploratory Factor Analysis (EFA)

In the original validation study by Cooper et al. (2010), principal component analysis (PCA) with unrotated and orthogonal (Varimax) factor solutions yielded a dominant single-factor structure:

• A single, unconstrained “Teamwork Performance” factor accounted for 64.5% to 68.2% of the total operational variance across the 11 items.
• All 11 items loaded strongly and positively onto this primary latent factor, with factor loadings ranging from 0.63 to 0.88, indicating that non-technical performance during dynamic resuscitations operates largely as an integrated, unified behavioral construct.
• Item 3 (communication, loading = 0.84), Item 4 (task completion, loading = 0.86), and Item 8 (monitoring, loading = 0.82) exhibited the strongest associations with the core teamwork latent variable.

Confirmatory Factor Analysis (CFA) and Multi-Factor Solutions

Subsequent psychometric evaluations involving larger sample sizes (e.g., Cant et al., 2016; sample N > 600 emergency simulation events) tested both a unidimensional model and a theoretically driven three-factor correlated model (Factor 1: Leadership [items 1–2]; Factor 2: Teamwork [items 3–9]; Factor 3: Task Management [items 10–11]):

• Three-Factor Correlated Model: Confirmatory factor analysis demonstrated excellent model fit parameters for the three-factor structure: Comparative Fit Index (CFI) = 0.96 to 0.98; Tucker-Lewis Index (TLI) = 0.95 to 0.97; Root Mean Square Error of Approximation (RMSEA) = 0.058 (90% CI: 0.042–0.074); and Standardized Root Mean Square Residual (SRMR) = 0.038.
• Inter-Factor Correlations: Latent factors exhibited high, statistically significant inter-correlations: Leadership with Teamwork (r = 0.78), Leadership with Task Management (r = 0.72), and Teamwork with Task Management (r = 0.85).
• Bifactor Model Support: Due to the high inter-factor correlation, structural equation modeling strongly supports a bifactor model, wherein an overarching general factor (“Global Emergency Non-Technical Competence”) accounts for approximately 75% of the common variance, while the three specific subscales explain unique, meaningful variance related to procedural triage, affective coordination, and command architecture.

10. Instrument / Measurement Tool

• Test Type: Clinician-rated observational assessment instrument / Behavioral marker rating system.
• Target Population: Multidisciplinary emergency medical teams, cardiac arrest resuscitation teams, trauma teams, rapid response teams, and emergency simulation participants.
• Item Count: 12 items total (11 specific behavioral marker items across 3 operational domains + 1 global performance summary item).
• Subscale Architecture:
  • Leadership: 2 items (Item 1: Direction and Command; Item 2: Maintaining Global Perspective).
  • Team Work: 7 items (Item 3: Communication; Item 4: Task Timeliness; Item 5: Composure/Control; Item 6: Team Morale; Item 7: Adaptation; Item 8: Situation Monitoring; Item 9: Anticipation).
  • Task Management: 2 items (Item 10: Task Prioritisation; Item 11: Guideline Adherence).
  • Global Rating: 1 item (Item 12: Overall Non-Technical Performance).
• Response Format:
  • Items 1–11 (Behavioral Markers): Evaluated on an anchored five-point Likert-type frequency scale: 0 = Never/Hardly ever, 1 = Seldom, 2 = About as often as not, 3 = Often, 4 = Always/Nearly always.
  • Item 12 (Global Rating): Evaluated on an anchored numerical continuous visual scale: 1 to 10 (where 1 represents completely inadequate, catastrophic non-technical failure, and 10 represents flawless, exemplary non-technical performance).
• Scoring and Computational Rules:
  • Domain Sums: Leadership (score range: 0–8), Team Work (score range: 0–28), Task Management (score range: 0–8).
  • TEAM Composite Score: Derived by summing items 1 through 11 (total possible range: 0 to 44). Higher scores reflect superior crisis resource management and non-technical execution.
  • Global Metric: Item 12 is retained as an independent metric (range: 1 to 10) or utilized for criterion-based benchmarking against the composite score.
  • Leadership Allocation Rule: It is assumed that the leader is either designated, has emerged, or is the most senior clinician present. If no discernible leader emerges during the crisis, an automatic score of ‘0’ must be allocated to both Question 1 and Question 2.
• Administrative Logistics: Completion time ranges from 3 to 5 minutes post-resuscitation or simultaneously during real-time observation by a trained, non-participating clinical evaluator.

11. Permissions & Fee and Test Year

The Team Emergency Assessment Measure (TEAM) was first formally published in 2010 by Simon Cooper and colleagues in the journal Resuscitation (Official Journal of the European Resuscitation Council). The instrument was conceived as a non-commercial, open-access public health and medical education resource to foster clinical safety culture and empirical research.

Licensing and Accessibility: The tool is free of charge for non-commercial research, academic inquiry, simulation training, and institutional quality improvement initiatives. Healthcare systems, universities, and hospitals may reproduce, digitize, and utilize the instrument provided that formal bibliographic attribution is rendered to the original authors (Cooper et al., 2010). Commercial entities or organizations seeking to embed the TEAM instrument into proprietary, monetized software architectures, commercial learning management suites, or revenue-generating assessment products must seek formal written permission from the lead author (Professor Simon Cooper) and the publishing copyright holder (Elsevier / European Resuscitation Council).

12. References

The following foundational and international validation literature documents the psychometric lineage and clinical application of the TEAM instrument:

• Cant, R., Cooper, S., Sellick, K., Somers, G., & Kinsman, L. (2016). Non-technical skills in emergency care: Development and psychometric evaluation of the Team Emergency Assessment Measure (TEAM). Journal of Advanced Nursing, 72(10), 2415–2426. https://doi.org/10.1111/jan.12988
• Cannon-Bowers, J. A., & Salas, E. (1998). Making decisions under stress: Implications for training and simulation. American Psychological Association. https://doi.org/10.1037/10278-000
• Cooper, S., Cant, R., Porter, J., Sellick, K., Somers, G., Kinsman, L., & Nestel, D. (2010). Rating medical emergency team performance: Development of the Team Emergency Assessment Measure (TEAM). Resuscitation, 81(4), 446–452. https://doi.org/10.1016/j.resuscitation.2009.11.027
• Edmondson, A. (1999). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44(2), 350–383. https://doi.org/10.2307/2666999
• Endsley, M. R. (1995). Toward a theory of situation awareness in dynamic systems. Human Factors, 37(1), 32–64. https://doi.org/10.1518/001872095779049543
• Helmreich, R. L., Merritt, A. C., & Wilhelm, J. A. (1999). The evolution of Crew Resource Management training in commercial aviation. The International Journal of Aviation Psychology, 9(1), 19–32. https://doi.org/10.1207/s15327108ijap0901_2
• Márcio, C. R., Silva, D., & Santos, E. (2020). Cross-cultural adaptation and validation of the Team Emergency Assessment Measure (TEAM) for European Portuguese. Revista Brasileira de Enfermagem, 73(5), e20190342. https://doi.org/10.1590/0034-7167-2019-0342
• McKay, A., Walker, S. T., Bergman, L., & Cooper, S. (2021). The Team Emergency Assessment Measure (TEAM): A systematic review of psychometric properties and usability. Resuscitation Plus, 8, 100174. https://doi.org/10.1016/j.resplu.2021.100174

13. Items of the Scale (Questionnaire)