Figure 1
Distributed Cognition, Relational Coordination and Cognitive Load in Collaborative Teamwork.
Table 1
Participant Demographics.
| DISCIPLINES | CLINICAL ENVIRONMENT | GENDER | CONTINENT | EXPERIENCE TOGETHER AS DYADS IN YEARS | NUMBER OF PROCEDURES TOGETHER |
|---|---|---|---|---|---|
| Nurse Anesthetist | Operating Room | Male | Europe | 15.0 | >100 |
| Cardiac Anesthetist | Operating Room | Male | |||
| Anesthesiologist | Operating Room | Female | North America | 4.0 | 50–100 |
| Ear, Nose and Throat Surgeon | Operating Room | Female | |||
| Obstetrician | Emergency Room | Female | North America | 1.0 | 10–50 |
| Emergency Physician | Emergency Room | Female | |||
| Neonatal Nurse | Neonatal ICU | Female | North America | 3.0 | 10–50 |
| Neonatologist | Neonatal ICU | Female | |||
| Midwife | Obstetrics Department | Female | Australia | 2.5 | 10–50 |
| Obstetrician | Obstetrics Department | Female | |||
| Emergency Nurse | Paediatric Emergency Room | Female | Australia | 14.0 | >100 |
| Emergency Physician | Paediatric Emergency Room | Male | |||
| Midwife | Labor and Delivery Room | Female | North America | 6.5 | >100 |
| Obstetrician | Labor and Delivery Room | Female | |||
| Surgeon- Ophthalmologist 1 | Operating Room | Male | Australia | 1.0 | >100 |
| Anesthetist 1 | Operating Room | Male | |||
| Surgeon- Ophthalmologist 2 | Operating Room | Male | Australia | 6.0 | >100 |
| Anesthetist 2 | Operating Room | Male | |||
| Bariatric Surgeon | Operating Room | Female | North America | 3.0 | >100 |
| Surgical Assistant | Operating Room | Female |
Table 2
Trust in Dyads.
| SUBTHEME | ILLUSTRATIVE QUOTE | DYAD |
|---|---|---|
| Trust as foundation | “Not that I don’t trust other people, it’s just you don’t know them, and I think, knowing people and them knowing a little bit about you, you know who they are, and you’re comfortable. That’s what is really beneficial in terms of a great-working relationship.” | Midwife and Obstetrician 1 |
| Psychological safety | “I know that [John] trusts my judgment. If I didn’t trust [John], I wouldn’t be able to go to him and feel psychologically safe in saying what my feelings are, because I’m just a nurse to some people.” | Emergency Nurse and Emergency Physician |
| Fragility vs abundance of trust | “Because if you can’t trust the other person, then you’re not part of a team. You have two people working and you’re doing your job and second guessing their job.” | Ophthalmologist and Anaesthetist.1. |
Table 3
Connectedness in Dyads.
| SUBTHEME | ILLUSTRATIVE QUOTE | DYAD |
|---|---|---|
| Familiarity | “Knowing people and them knowing a little bit about you is really beneficial in terms of a great working relationship.” | Midwife and Obstetrician 1. |
| Transparency | “He is able to speak out loud all of his thoughts, and because he says what is happening, everyone is able to talk out loud.” | Anaesthetist and Anaesthetic Nurse |
| Levity/humour | “We’ll text each other stupid memes; it doesn’t break the flow, but it just sort of resets us.” | Obstetrician and Emergency Physician |
Table 4
Situation Awareness in Dyads.
| SUBTHEME | ILLUSTRATIVE QUOTE | DYAD |
|---|---|---|
| Shared context | “Understanding the surroundings and understanding each other makes us able to handle patient care issues together.” | Obstetrician and Emergency Physician |
| Emotional atunement | “He understands how others are feeling in the room, initiating reflection if a process has broken down.” | Ophthalmologist and Anaesthetist 1. |
| Shared mental models | “Shared communication is the most important bit to generate shared mental models of what performance should be like, and why.” | Ophthalmologist and Anaesthetist 2. |
Table 5
Physical Communication in Dyads.
| SUBTHEME | ILLUSTRATIVE QUOTE | DYAD |
|---|---|---|
| Rapid coordination | “We can just look at each other; and you know how serious it is without saying anything.” | ENT Surgeon and Anaesthetist 1 |
| Emotional support | “I put my hand on his shoulder and said ‘breathe’; it grounded us both.” | Emergency Nurse and Emergency Physician |
Table 6
Reflective Practice in Dyads.
| SUBTHEME | ILLUSTRATIVE QUOTE | DYAD |
|---|---|---|
| Pre-briefing | “We had a conversation about what the plan would look like; a brief huddle about the day.” | Neonatal Nurse and Neonatologist |
| Collaborative problem-solving | “Whenever there’s a grey area, we talk about it collaboratively, knowing we might have to change the plan.” | Ophthalmologist and Anaesthetist 1. |
| Debriefing | “I like it a lot when I go to my colleagues and say, ‘what do you think of our work?’. Just with a coffee at the end of the day.” | Anaesthetic Nurse and Anaesthetist |
Table 7
Repetition of Themes among Dyads.
| THEME | DYADS (OUT OF 10) WITH STRONG/CENTRAL MENTION |
|---|---|
| Trust | 10/10 |
| Physical communication | 10/10 |
| Situation awareness including shared mental models | 10/10 |
| Connectedness including complimentary behaviours and role synergy | 10/10 |
| Reflective practice including debriefing | 9/10 |
| Boundaries including no public critique and respectful norms | 8/10 |
| Emotional regulation including being calm under pressure and co-regulation | 8/10 |
| Psychological safety and safe feedback | 7/10 |
Table 8
Analysis of Patterns Stemming from Dyadic Experience.
| RELATIONSHIP/PATTERN | ANALYSIS | CAVEAT/POTENTIAL CONFOUND |
|---|---|---|
| When there was greater dyad familiarity, there was a higher shared volume of work and more explicit physical and gestural cues were deployed. | In dyads that had worked many years or many procedures together (e.g. >100), there was more mention of subtle gestural coordination (eye cues, small gestures) than in dyads with shorter tenure. | This could be a visibility bias. For example; when people know each other well, they notice these cues. |
| When there was more experience, (such as years in a role) there was more talk about emotional regulation and calmness. | Older, more senior participants more often spoke of staying calm, hiding emotion, or co-regulating under pressure. | Senior clinicians might also feel more able to articulate these emotions, so reporting bias might play a role. |
| Dyads with a strong learning culture (simulation, debriefs) tend to also emphasize psychological safety. | Where debriefs, feedback, and structured learning were strong, participants more often spoke about being safe to speak up, making mistakes, or emotional processing. | It may be that the same relational qualities (trust, openness) grow when there is more experience together, ensuring more psychological safety. |
| In dyads with more cross-discipline overlap (e.g. surgeon and anaesthetist) there was stronger talk of shared mental models, planning, and decision alignment. | In surgical/anaesthesia dyads, participants often mentioned stress pre-case, and so planned alignment, intra-case updates, and spoke of adapting together. | These dyads may inherently require more coordination, so the theme is situationally more visible. |
Table 9
The Collaborative Practices Table; Relational vs Cognitive Behaviours and Attitudes.
| COLLABORATIVE PRACTICES TABLE — RELATIONAL VS COGNITIVE | |||
|---|---|---|---|
| PRACTICE/STRATEGY | RELATIONAL (INTERPERSONAL, AFFECTIVE) | COGNITIVE/STRATEGIC (THINKING, COORDINATION) | SAMPLE INDICATORS/NOTES |
| Trust | vulnerability, reliability, moral alignment | predictability, transparency, consistency | Many dyads said “I trust that she’ll do X”; trust developed over time. |
| Connectedness/Rapport | banter, personal stories, empathy, checking in | Dyads often “like each other,” share non-clinical chat. | |
| Shared Mental Models/Pre-planning | aligning mental models, “what if” scenarios, defining endpoints | Pre-briefs, discussing a plan before the case starts. | |
| Situation Awareness | reading partner cues, attention to environment | anticipating changes, scanning for cues, updating the mental model | Nonverbal cueing, mid-case updates, coordinate and adaptation. |
| Physical Communication | eye contact, posture shifts, touch, gestures | using gestural cues to coordinate timing, signalling | Gestures, shoulder taps, glance cues, spatial orientation |
| Reflexivity Reflection/Debriefing/Feedback | safe voice, open discussion, emotional processing | micro-analysis, “what went well/what not,” feedback loops | Many dyads do after-action reviews and informal post-case talk. |
| Boundary Norms/Conflict Avoidance | norms about not criticizing publicly, respectful tone | rules about where/when disagreement is aired | “We don’t disagree in front of the patient,” private resolution |
| Emotional Regulation/Co-regulation | calming presence, managing partner’s emotional state | maintaining focus under stress, regulating cognitive load | Dyads mention staying calm, mutual support when tense |
| Role Clarification/Complementarity | recognizing each other’s domain, respecting autonomy | distributing tasks, determining who leads in which domain | “She handles X, I handle Y,” seamless role handoffs |
| Learning Practices (Simulation, Checklists) | shared humility, joint improvement | structured tools, checklists, simulation, measurement | Use of simulation, checklists, experimenting, adopting new methods |
| Conflict Management/Tension Resolution | Airing disagreement respectfully and repairing relational strain | Negotiation, boundary enforcement, feedback timing | Some dyads mention “heated discussion” and always with resolution discussion |
Figure 2
The Expert Dyad Framework.
Table 10
The Collaborative Micro-Practices used by Expert Dyads.
| DYAD | COLLABORATIVE MICRO-PRACTICES | EXPERT DYAD FRAMEWORK CATEGORIES |
|---|---|---|
| Obstetrician and Emergency Physician | Including the other in early tasks | Situation Awareness |
| Delivering reliably on commitments | Reflective Practice/Situation Awareness | |
| Frequent touchpoints/meetings | Physical Communication/Connectedness | |
| Naming expectations and reflecting together | Reflective Practice | |
| Midwife and Obstetrician 1. | Sharing decisions together | Situation Awareness |
| Gradually relinquishing control | Reflective Practice | |
| Reflecting on roles and affirming ownership | Reflective Practice/Connectedness | |
| Emergency Nurse and Emergency Physician | Giving nurturing feedback | Connectedness/Reflective Practice |
| Rotating through shared duties/exposure | Situation Awareness/Connectedness | |
| Social interaction (casual chats) | Connectedness | |
| Consistency in alignment of style | Physical Communication/Connectedness | |
| Midwife and Obstetrician 2. | Consistent scheduling together | Physical Communication |
| Observing shared mindset/approach | Situation Awareness | |
| Gradually letting the other take on tasks | Reflective Practice | |
| Adopting shared leadership norms | Reflective Practice/Connectedness | |
| Ophthalmologist and Anaesthetist 1. | Debriefing item by item | Reflective Practice/Situation Awareness |
| Discussing “why” behind standards | Reflective Practice | |
| Reflecting on system design & team flows | Reflective Practice/Situation Awareness | |
| Ophthalmologist and Anaesthetist 2. | Asking “what happened?” in non-blaming way | Reflective Practice/Situation Awareness |
| Talking through timing/micro adjustments | Situation Awareness | |
| Reflecting on team flow and patient experience | Reflective Practice/Connectedness | |
| Surgical Assistant and Surgeon | Being paired consistently by management | Physical Communication/Connectedness |
| Coordinating schedules | Physical Communication | |
| Senior scaffolding junior’s learning | Reflective Practice/Situation Awareness | |
| Junior gradually contributing fully | Reflective Practice | |
| Anaesthetic Nurse and Anaesthetist | Intensive shared simulation training | Connectedness/Physical Communication |
| Emotional/communication work in simulation | Connectedness/Reflective Practice | |
| Co-teaching over years | Situation Awareness/Connectedness | |
| Surgeon and Anaesthetist | Collaborating early on a critical case | Situation Awareness/Connectedness |
| Noting shared background/identity cues | Connectedness | |
| Explicitly resolving disagreements | Reflective Practice | |
| Maintaining openness through disagreements | Reflective Practice/Connectedness | |
| Neonatal Nurse and Neonatologist | Informal hallway/incidental meetings | Physical Communication/Connectedness |
| Observing caring gestures (notes, small touches) | Physical Communication/Connectedness | |
| Consistency of words and actions | Physical Communication/Reflective Practice | |
| Demonstrating care under pressure | Situation Awareness/Connectedness |
Table 11
Positioning the Expert Dyad Framework within contemporary teamwork literature.
| FRAMEWORK | CORE FOCUS | STRENGTHS | LIMITATIONS/GAPS | EXPERT DYAD FRAMEWORK MICRO-PRACTICES |
|---|---|---|---|---|
| Big Five Teamwork (Salas, Sims & Burke, 2005) | Five core teamwork processes (team leadership; mutual performance monitoring; backup behaviour; adaptability; team orientation) supported by coordinating mechanisms (shared mental models; closed-loop communication; mutual trust) | High theoretical grounding; serves as a clear, parsimonious framework for team effectiveness across contexts; widely cited in the teamwork literature | Operates at team level rather than fine-grain dyadic micro-interaction; lacks direct focus on physical signalling, glance/gesture, micro-relational calibration in pairs | EDF complements this by specifying micro-practices like gestural cueing, relational calibration, emotional atunement, subtle boundary signalling between two interacting individuals |
| TeamSTEPPS King H, Battles J, Baker DP, Alonso A, Salas E, Webster J, Toomey L, Salisbury M. TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety. Rockville, MD: Agency for Healthcare Research and Quality; 2006. | Standardized teamwork skills: communication, leadership, situation monitoring, mutual support, role clarity | Widely adopted; provides practical tools and training modules | Treats dyads as mini teams without specifying micro-coordination; limited focus on relational calibration or non-verbal signalling | Specifies gestural cueing, relational calibration, emotional atunement, boundary norms for disagreement and micro-adjustments mid-interaction. |
| Team FIRST Greilich PE, Kilcullen M, Paquette S, Lazzara EH, Scielzo S, Hernandez J, et al. Team FIRST framework: Identifying core teamwork competencies critical to interprofessional healthcare curricula. J Clin Transl Sci. 2023;7(1):e106. | 10 teamwork competencies: recognizing teamwork, psychological safety, structured communication, closed loop, clarifying questions, sharing unique info, optimizing mental models, mutual trust, mutual performance monitoring, reflection/debriefing | Strong, evidence-based, tailored to healthcare; emphasis on interprofessional curricula | Operates at team level; less attention to how two individuals dynamically coordinate via gesture, glance, emotional regulation | EDF shows how Team FIRST competencies are embodied in dyads—e.g. how “structured communication” becomes gaze shifts or minimal cues; how “mental model alignment” becomes micro calibration and checking |
| Frontiers Healthcare Team Effectiveness Framework Zajac S, Woods A, Tannenbaum S, Salas E, Holladay CL. Overcoming Challenges to Teamwork in Healthcare: A Team Effectiveness Framework and Evidence-Based Guidance. Front Commun. 2021; 6:606445. | Broad challenges to teamwork in healthcare: accountability, conflict, decision making, reflection, communications, context (from qualitative + survey data) | Useful at system/team levels; identifies common barriers and enabling strategies | Doesn’ zoom into micro pair interaction; conflict and relational drift under-specified | EDF brings forward relational repair, micro-conflict norms, co-regulation under stress, and fine grain relational gestures |
| Relational Coordination/Relational Perspectives Gittell JH, Godfrey M, Thistlethwaite J. Interprofessional collaborative practice and relational coordination: Improving healthcare through relationships. Journal of Interprofessional Care. 2013;27(3):210–3. | Emphasis on work coordination via relationships: shared goals, shared knowledge, mutual respect, frequently timely communication | Excellent for linking relational and structural coordination at team/organizational levels | Less emphasis on how individuals enact relational coordination in minute-by-minute interaction | EDF shows how relational coordination is embodied: through glance cues, touch, micro reflection, mutual atunement in dyads |
| Dyadic Leadership/Dyad partnership models Clouser JM, Vundi NL, Cowley AM, Cook C, Williams MV, McIntosh M, Li J. Evaluating the clinical dyad leadership model: a narrative review. J Health Organ Manag. 2020;34(7):725–741 | Role alignment, shared vision, trust, communication in leader–co-leader dyads (mostly administrative/strategic) | Focuses on pair relationships, role negotiation, trust | Usually distant from clinical micro-interaction, limited in capturing split-second cueing or emotional regulation in high pressure | EDF brings micro-relational responsiveness, calibration under pressure, feedback loops between two people, and micro experiential reflection in clinical dyads |