Team decision-making in high-stakes time-pressured environments: what helps and what hinders?

Team decision-making is central to effective practice in high-acuity healthcare environments, yet most decision-making research in medicine remains focused on individuals rather than teams. This narrative review synthesizes evidence across various fields, including aviation, military, crisis response, and team sport, to identify key factors that influence team decision-making in time-bound, high-stakes settings, and to examine how these insights may inform practice in acute care and resuscitation medicine.

A systematic search of MEDLINE and Scopus databases following previously identified best practices for narrative review identified 595 unique records; after review by the first and second authors, 25 studies met inclusion criteria and focused explicitly on team-level decisions made under conditions of time pressure and high stakes. Included studies spanned healthcare, emergency response, crisis management, aviation, sport, business, and military contexts. These studies were then analyzed by the first author and themes were identified.

Content analysis revealed five factors shaping team decision-making: role clarity, hierarchy, information sharing, team cognition, and team training. Across domains, clear and mutually understood roles have been shown to facilitate coordination, whereas role ambiguity resulted in conflict, redundancy, or unsafe task prioritization. Flexible, psychologically safe hierarchies, rather than rigid structures, enabled inclusive communication and reduced deference-based errors. Effective information sharing required both sufficiency and restraint, emphasizing relevance, timeliness, and shared situational awareness. Team cognition, including the development of shared mental models, was foundational for synchronizing actions under dynamic conditions. Finally, team training approaches that emphasize adaptability, cross-role understanding, pre-briefing, and debriefing cultivated resilience and improved decision accuracy under pressure.

These findings suggest opportunities to strengthen decision-making in acute care by prioritizing early role clarification, flattening communication pathways, and designing training that targets soft resilience, shared cognition, and adaptive communication.