EP Research

Leadership and Peer-to-Peer Education: Key Aspects for Team Building in the Lab

Angela Murphy, BS, RCIS

Orlando, Florida

Angela Murphy, BS, RCIS

Orlando, Florida


In labs such as a cardiac catheterization lab (CCL), varied groups of healthcare workers come together day and night to save the lives of patients in cardiac crisis. The members of the group usually include two registered nurses (RNs) and two cardiovascular technologists (CVTs); CVTs can be either registered cardiovascular invasive specialists (RCIS) or radiology technologists (RT). Yet despite this expertise and knowledge, instances can sometimes occur in which staff members are either unprepared or unwilling to help their colleagues, even in emergency situations. It is a topic that frustrates those in CCLs, electrophysiology labs, and even surgical suites, throughout hospitals. There are several possible reasons for this. For example, it may be due to the overall health of the work environment in the CCL. For others, it may be because team members do not realize they have knowledge worth sharing. Some also may lack the confidence and skills on new equipment being brought into the lab. Some may have a fear of being replaced, or are even resentful of leadership or hiring practices. However, these factors can lead to increased medical errors and decreased patient safety. Each member of the team brings a skill set and a role that is vital to saving patients. The aim of this article is to evaluate whether peer-to-peer education and a mandatory leadership approach can build stronger teams and empower lab staff. 


A search of healthcare databases was performed to help evaluate whether leadership styles that include mandatory peer-to-peer education build more dynamic teams in the CCL. The databases used included MEDLINE with full text (EBSCO), Gale Nursing and Allied Health, and Allied Health / Nursing (EBSCO), among others. The search performed included only full-text, peer-reviewed articles from 2016 to the present. Using key words, five articles were chosen to be most directly related to showing that either peer-to-peer education is necessary for team building, or that no correlation exists between leadership styles, peer-to-peer education, and team dynamics. The works are reviewed here and demonstrate that peer-to-peer education is critical to team success and should be more closely addressed by leadership to help improve team dynamics and reduce medical errors. 

Literature Review

Cardiac labs make up an important percentage of the corporate operations of hospitals. Therefore, supplies purchased and delivery of services must be efficiently managed, and effective leadership should be a top priority. In 2018, Reed et al published their research on operational efficiencies and effective management strategies in the CCL, with a primary focus on leadership strategies.1 They demonstrated that in the CCL, there are differences between quality and efficiency.1 The American College of Cardiology and other organizations have previously established the practices that define the standard of care, which should be the prevailing goal in CCLs. Efficiency is described as how production measures up with expenses. Those expenses include dollars spent not only on supplies, but also on staff and other necessary personnel resources. In the CCL, time management is also critical. Reed et al outlined a congruence model for CCL improvement, including leadership’s awareness of each person’s duties, and the actual time it takes to perform these duties. This can be accomplished most effectively with a timeline for each employee. However, they confirmed that the most important component is human resources. Physicians and staff should have varied skills, speed, and caseloads that create varied timelines. “Maintaining motivated and engaged employees is key to executing transformation change … managers should pay attention to employee satisfaction during this process and elicit feedback.”1 Their research demonstrates that the most dynamic teams in the CCL consist of a mixture of skill levels. Leadership must be able to gauge the environment in the CCL. Keeping employees confident and happy in their work is key. Costs and other measures can be contained, but the CCL will run more efficiently if employees are interested and stimulated. 

Research has also shown that unhealthy work environments can lead to staff conflict, animosity, and poor communication, as well as negatively impacted patient outcomes. Leadership styles that determine the mood of the lab can be very effective. Hinsley et al showed that leadership can use simple tools for monitoring the health of the CCL work environment.2 They developed a consensus-based method that was completed by staff members but overseen by a quality control committee. The six-point numerical scale used visual images resembling emoticons on hospital white boards; employees were asked to circle the face that matched the sentence that met the description of their feelings. Higher numbers corresponded to a more positive experience. The survey also included two questions asking for a short answer on what was good and what could be improved. Example responses included, “4: Good Day, pleasant interactions, job well done” or “1: Frustrated, I need a vacation, can’t believe I got out of bed for this.”2 Since surveys could remain anonymous, employees generally felt freer writing in their concerns. Also, since it was overseen by an outside committee from the CCL, leadership only saw the comments and the graph of the mood of the lab. The staff could complete these 10-12 times each month. In fact, the tool became so popular at their hospital, that staff were participating 25 or more times per month. As the survey developed, a scale was added to some departments for employees to identify specifics such as supportive atmosphere, teamwork, etc. A graph was later created from the surveys and provided to leadership to show the overall health of the work environment in the CCL and other areas of the hospital. Targeted initiatives followed, such as modifying staffing from all 12-hour shifts to a mix of 10- and 12-hour shifts. The research found that leadership can find creative ways to find out how the employees are feeling and what their concerns are in a manner that is quick and informative. This research also showed that leadership can get input from team members and act effectively to help employees feel empowered. Assessing the overall health of the work environment can help pinpoint the needs of the lab, remove any animosity that may exist, and lead to a better and more productive work atmosphere.

While leadership styles may vary, Sfantou et al discussed the value of a transformational leadership style in the healthcare setting to encourage staff members to educate their peers and bring quality of care.3 They identified six different leadership styles using 18 articles published between 2004 and 2015.3 One style of leadership highlighted was transformational leadership. The authors explained that “Transformational leadership style is characterized by creating relationships and motivation among staff members. Transformational leaders … communicate loyalty through a shared vision, resulting in increased productivity, strengthen[ed] employee morale, and job satisfaction.”3 Their research showed that a transformational leadership style was associated with creating an overall culture of patient safety, which translated into improved process quality, organizational culture, patient outcomes, and overall quality of care.3 A transformational leadership style had the most impact on employees, and the result was a high-quality work environment with improved patient outcomes. 

The learning curve associated with new technological advances in the lab is another important area of consideration. With an increased complexity of procedures, novices may not be completely confident in their skills and may need additional training and education. A mentor can make all the difference, but there is another way that everyone on the team can be prepared. Aggarwal et al demonstrated that every member of the team in the CCL, including physicians, benefit by simulation of procedures.4 Their research focused on several types of simulation, including virtual reality, to prepare the team in advance and work through solutions. Simulation trained diverse staff members on procedures and products, decreased the learning curve for novices, and provided interventionalists with additional skills. Simulation was shown to be helpful in enhancing motor skills, cognitive abilities, and hand-eye coordination. Simulating emergencies with staff also not only allowed for equipment preparation and improved skill, but helped with hemodynamic monitoring and management as well as assessment of pharmacological responses to various medications for faster response times.4 Performance from all aspects was positively impacted when real-time critical duties were performed. Team members worked together much more effectively, which ultimately can lead to better patient outcomes. Thus, simulation and peer-to-peer education can be vital to team dynamics and patient safety. Improved skills lead to better teams, creating a better working environment and better patient outcomes. 

Lastly, it is important to address the aspect of teamwork in healthcare. Teams can accomplish much more than individuals working independently; however, sometimes a culture in the CCL is created in which some members of the team are viewed as more valuable than others. The CCL should be filled with varying skills and knowledge, as well as have people that want the best for the team. In order to create a healthy and productive team, effective leadership styles must capitalize on every person in the lab. Mayo and Woolley revealed the vital importance of team knowledge sharing and its relationship to patient safety.5 According to their research, leadership should put the most value in “two communication processes: ensuring that team members with relevant knowledge (1) speak up when one’s expertise can be helpful and (2) influence the team’s work so that the team does its collective best for the patient.”5 Teams that follow these two methods can expand care to patients because they are problem solving and completing tasks together rather than individually. When communication and collaboration fail, medical errors can occur and quality of care is reduced. However, Mayo and Woolley also found that having only the smartest and most experienced people in every position does not create better teamwork or outcomes.5 They present the concept of a collectively intelligent team, or the team’s general ability to perform a variety of tasks. The challenge that most often occurs in teams is when team members do not realize they have knowledge worth sharing. Stereotypes and cultures previously created in the CCL also can prevent team members from speaking up, because they incorrectly assume others already know or that no one wants to hear what they have to say. In addition, leadership must create a workplace where people are not bullied, punished, or embarrassed for speaking out. Instead, it is vital for teams to participate in inclusive behavior, such as acknowledging those that help to educate the team. Leadership must specifically ask direct questions about whether employees have been contradicted negatively, and immediately act on the information. At that time, everyone can become more accepting of one another. Mayo and Woolley conclude that those in leadership positions or of higher rank in the CCL should actively invite information from other team members, offering guidance, praise, and appreciation. Collaboration of knowledge leads to a more dynamic team and better patient care.


The research presented here demonstrates that leadership styles that include peer-to-peer education can build dynamic teams in the CCL. The research also suggests various solutions for leaders to create collaborative teams that appreciate working together for the goal of saving lives. All healthcare staff interested in creating an ethical and diverse culture in the lab should review what has been presented. Knowledgeable teams that want the best for each other can bring true empathy to the CCL by including every member. 

Disclosures: Ms. Murphy has no conflicts of interest to report regarding the content herein.

  1. Reed GW, Tushman ML, Kapadia SR. Operational efficiency and effective management in the cardiac catheterization laboratory: JACC review topic of the week. J Am Coll Cardiol. 2018;72(20):2507-2517.
  2. Hinsley KE, Marshall AC, Hurtig MH, et al. Monitoring the health of the work environment with a daily assessment tool: the REAL — Relative Environment Assessment Lens — indicator. Cardiol Young. 2016;26:1082-1089.
  3. Sfantou DF, Laliotis A, Patelarou AE, Sifaki-Pistolla D, Matalliotakis M, Patelarou E. Importance of leadership style towards quality of care measures in healthcare settings: a systematic review. Healthcare (Basel). 2017;5(4).
  4. Aggarwal S, Choudhury E, Ladha S, Kapoor P, Kiran U. Simulation in cardiac catheterization laboratory: need of the hour to improve the clinical skills. Ann Card Anaesth. 2016;19(3):521.
  5. Mayo AT, Woolley AW. Teamwork in health care: maximizing collective intelligence via inclusive collaboration and open communication. AMA J Ethics. 2016;18(9):933-940.