How to Pivot Your Team Under Pressure

An abrupt change of direction.

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It’s a challenging operation combining significant pressure with high stakes for your team and your organization. Your plan was well-developed, and your team was executing admirably when suddenly everything went sideways and the situation changed rapidly.

As the leader, it’s clear that your team will need to change directions quickly if it wants to stay in the game, but how can they do that while still actively performing under pressure? How can you help your team successfully pivot to a new focus mid-sprint?

In the emergency department, we face this scenario on an all-too-regular basis. A patient’s condition changes rapidly, or a plan fails unexpectedly, requiring your team to shift to a different plan of action. Or perhaps multiple other patients arrive during a critical resuscitation, requiring you to unexpectedly spread your team into two or three different trauma bays.

Changing directions like this at high speeds can be confusing or even dangerous for your team and your patient. It’s not enough to just say, “Do this now instead." You have to make sure everyone on the team is playing the same game and knows the new plan.

So, assuming slowing down and smoothly pivoting is not an option, here are three ways we pivot under pressure in the world of emergency medicine that you can put into practice with your team.

Set the stage and announce what’s coming.

Sometimes during a crisis, everything moves so fast that all you can say is, “Turn now!” Often though, there’s time to do more to set the stage for the pivot, and giving even a little warning can yield huge benefits for your team’s performance.

A standard way we announce what’s coming in the ER is: gather, plan, priority. You gather the team’s attention, share the plan for what’s about to change, and state the immediate next priority. Then, you turn them loose to get to work executing.

For example, consider a team working with someone suffering from a severe allergic reaction. Your team has delivered the first-line therapies, but they’re not working, and you see the patient getting worse, and you know you’re going to need to switch plans and place them on a breathing machine.

In this case, you might say something like, “Team–in a moment, we need to pivot controlling the airway. Priority is establishing IV access and getting intubation meds to bedside.” Gather, plan, priority.

Doing this gives your team a moment to reflect on their immediate next steps and how those next steps align with the new overarching goal. Obviously, the more warning and slower the turn, the better, but even a little advance notice cuts friction and helps your team execute the new plan.

Take advantage of natural rhythms and breaks.

Most high-stakes situations actually have a natural rhythm to them if you look closely. Markets close and open at different times. Tennis matches have breaks between sets. Even cardiac arrests have pauses between cycles of CPR for pulse checks.

While the pressure of performing at an elite level doesn’t entirely go away during these moments, it typically is slightly less. If you can find these moments, you can use them to pivot more easily.

I found this extremely difficult to comprehend when I was just learning to perform under pressure. Everything seemed like it was moving so fast, it felt like there was no way to take my foot off the gas, even for a second. With practice, though, I was able to find the rhythm and use these natural breaks to more easily pivot my team.

One quick way you can start finding them: look for physical changes in the space around you. Is someone entering or leaving the room? Does a system need to be switched on or off? Anytime there’s a physical change, there’s the possibility of a pivot.

Pre-Plan Potential Pivots (P4)

If you have an idea of a pivot you might need to make, let your team know and make time together to work through how it would happen. “Team–we’re going to start with A, but we might need to go to B to get it done. Let's talk about what A to B would look like."

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This is critically important when you’re about to start a high-risk operation or procedure. Set your plan, then identify the most probable backup plan. Map out both plans, and also explicitly map the pivot between them.¹

When setting this up, ask your team ahead of time to think through what they will need to accomplish to make the transition. What barriers do they see to success? What do they (and you) need to do now to overcome those?

This way, if or when you do have to pivot from A to B, your team has already gone through the mental exercise of planning it out. You’re setting them up for success and eliminating unnecessary opportunities for failure.

Changing directions under pressure is never easy. As a leader, you might not be able to change the situation or slow down to pivot comfortably, but with these tools, you can absolutely make enormous differences in how your team pivots under pressure. How could you start applying them today?