This assignment focuses on teamwork and the management of patients requiring emergency treatment. In health care, teamwork or inter-professional collaboration is an essential component of safety. As breakdowns in teamwork can lead to poor patient safety, I aim to critically evaluate and defend the importance of inter-professional collaboration in the resuscitation department. Example scenarios of patients that were brought into the resuscitation department requiring immediate care management will illustrate different team approaches to working, barriers to effective team working, and leadership of teams. The nurse’s role in the maintaining patient safety via risk management strategies will also be explored. This is important because the resuscitation department is a fast paced environment potentially vulnerable to risks. I intend to conclude how each scenario was managed and from these, draw up recommendations for streamlined nursing care and inter-professional team working in a resuscitation department. A reference list is included.
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Introduction
In the Accident and Emergency (A&E) department, a key function is to receive asses and treat injured or sick people quickly at any time of the day or night. Anything can appear in an A&E department; from patients with cuts, sprains and limb fractures, to patients with more serious life threatening conditions such as cardiovascular emergencies, gastrointestinal problems, neurovascular emergencies and traumatic injuries. Due to the nature of work in this environment, nursing care and management often occurs as a rapid sequence of events commencing with the recognition of life-threatening needs (Etherington 2003).
Patients attending A&E are seen immediately and there needs for treatment assessed. This initial assessment is a process known as ‘triage’ designed to allocate clinical priority (See appendix). The Manchester triage group set up in 1994 is the most widely used triage method in the UK. The system selects patients with the highest priority first and works without making any assumptions about diagnosis. This is deliberate as A&E departments are largely driven by patients presenting with signs and symptoms (Mackaway-Jones 1997).
Once patients are triaged they are categorised according to a scale of urgency. The triage scale is colour coded for example: patients requiring immediate resuscitation and treatment are coded red, and would normally be met by a team ‘standing by’ after prior notification by the ambulance service (Crouch and Marrow 1996). People presenting with serious injury or illness require a skilled team who follow recognised life support protocols within agreed roles (Etherington 2003).
This assignment will focus on red coded patients brought into a resuscitation department requiring immediate care management for the preservation of life. Effective management of these patients is pivotal in reducing mortality rates and a skilled team is of great importance. In health care, teamwork or inter-professional collaboration is an essential component of safety. Research suggests that improvement in patient safety can be made by drawing on the science of team effectiveness (Salas, Rosen and king 2007). However, literature regarding emergency teams suggests that human factors such as communication and inter-professional relationships, can affect a team’s performance regardless of how clinically skilled the team members are (Cole & Crichton 2006, Lynch and Cole 2006). Ineffective teamwork can lead to errors in diagnosis and treatment (Salas, Rosen and king 2007) and is apparent in the many accusations of poor care and inadequate communication evident in malpractice lawsuits (Groff 2003).
As breakdowns in teamwork can lead to poor patient safety, I aim to critically evaluate and defend the importance of inter-professional collaboration in the resuscitation department. Example scenarios of patients that were brought into the resuscitation department requiring immediate care management will illustrate different team approaches to working, barriers to effective team working, and leadership of teams. The nurse’s role in the maintaining patient safety via risk management strategies will also be explored. This is important because the resuscitation department is a fast paced environment potentially vulnerable to risks. I intend to conclude how each scenario was managed and from these, draw up recommendations for streamlined nursing care and inter-professional team working in a resuscitation department.
Throughout this essay, I will adhere to confidentiality as stated in the Nursing Midwifery Council’s Code (2008) and no identities regarding the patients or the trust shall be named. I acknowledge that some reference sources used in this assignment are dated, however they are still commonly cited in much up-to-date literature.
The resuscitation room and the nurse’s role
The resuscitation room is designed for the assessment and treatment of patients whose injury or illness is life-threatening (Etherington 2003). Anything can emerge with little warning (Walsh and Kent 2000) however, departments often receive prior warning of a patient’s arrival which allows the preparation of the resuscitation area and the team (Etherington 2003). All team members should be appropriately prepared to care for the patient in a systematic manner. A&E nurses are vital components of the team (Hadfield-Law 2000) because they are usually among the first team members to meet patients and typically remain with them throughout their stay within the department (O’Mahoney 2005).
A nurse with advanced life support (ALS) training is best placed to care for patients in the resuscitation room (Etherington 2003). This is where their training can be best utilized and this assists the inter-professional team to practice mutual working skills modelled on evidenced based protocols (DH 2005).
Successful resuscitation depends on a number of factors, many of which can be influenced by A&E nurses such as the environment and the equipment. Patient (2007) highlights various elements of A&E nurses role in the preparation for patient arrival. This would include preparing the area, having equipment in ready and working order and having a team on ‘stand by’. These tasks underline the risk management strategies involved in maintaining a safe environment such as checking and cleaning everything on a regular basis (Etherington 2003), a practice which I observed is routinely carried between patient occupancy. The importance of carrying out such checks contributes to teams being prepared with equipment ready and working to treat patients safely.
Once the patient has arrived, other roles and tasks the A&E nurse might undertake include: maintaining a patient’s airway, patient assessment, taking vital observations, monitoring intravenous therapy, managing wound care, pain management, keeping rubbish clear to maintain a safe working environment, catheterisation, and communication and liaison between patients, relatives and the inter-professional team (Patient 2007, Etherington 2003). McCloskey et al., (1996) cited in Drach-Zahavy and Dagan (2002) describe this linking role of nursing as ‘glue function’ as it is nurses who maintain the holistic overview of the care given to the patient by all members of the inter-professional team.
From the literature (Patient 2007, Etherington 2003, McCloskey et al., 1996), it is evident that nurses working in the resuscitation area must be able to integrate with the inter-professional team and not only maintain the safety of the patient, but also everyone working in that environment. It is the nurse’s responsibility to manage the resuscitation room which incorporates preparing the environment and ensuring equipment is in working order.
Investigation into the resuscitation room and the nurse’s role within that area has highlighted that nurses have many important management roles to carry out. For the purpose of this assignment, focus will be upon the nurse working as part of the inter-professional team, and the risk management strategies that take place to support that team.
I had the opportunity to observe how inter-professional teams worked together to benefit the patient and ensure safety. Two examples of patients brought into the resuscitation department within the same week will now illustrate different team approaches to care management.
Example 1
10:00 Saturday morning, the department receives a call from ambulance control warning that they have a patient with cardiac arrest on the way in approximately ten minutes. Immediately the lead nurse of the emergency department informs the two nurses managing the resuscitation department of the patient en route. The Nurses put a call out to the emergency inter-professional team to stand by and prepared the area by having the defibrillator in position, the oxygen mask ready and the adrenaline at hand.
The emergency inter-professional team start flooding into the area and there is a mixture of bodies standing around in rubber gloves and aprons. The team consisted of three nurses, an anaesthetist, a physician’s assistant, two junior medical students, two nursing students, a registrar, and a consultant equating 11 people.
The ambulance crew arrived and they rushed the patient in promptly transferring her over from stretcher to trolley. The paramedic commenced a detailed handover to the team. The patient was a 69 year old woman who was found unconscious and not breathing at a holiday camp. The ambulance crew had been doing cardiac pulmonary resuscitation (CPR) for 45 minutes from scene to hospital. The patient was still not breathing. During the time of this handover, it was observed by the nurse that there was a short hesitancy between continuity of CPR. After the ambulance crew transferred the woman over to the trolley, no one took the lead of directing the team or continuing CPR. After this brief hesitancy a nurse took the lead by suggesting someone start CPR. Another nurse then stepped forward and commenced chest compressions whilst the anaesthetist placed a bag and mask over the patients airway. The team crowded around and the consultant stepped forward and started making orders loudly in relation to current advanced resuscitation guidelines.
The defibrillator was attached and the team was advised by the nurse operating it to stand clear. Shocks were delivered without success. The team took it in turn to do chest compressions for fifteen minutes whilst other members gathered around obtaining intravenous access. The consultant then suggested that they stop. The team stood back and started to disperse out of the resuscitation room leaving the nurses to continue care and management of the patient and her family. The patient was disconnected from the defibrillator and a nurse cleaned the resuscitation area.
Example 2
At 02:30 ambulance control report that they have a patient involved in a road traffic collision (RTC) on route due in approximately twenty minutes. The lead nurse informs the two nurses running the resuscitation area who then inform the inter-professional team to stand by. The resuscitation area is prepared and a team of seven including two nurses, a registrar, an anaesthetist, a physician’s assistant, an orthopaedic doctor, and a nursing student await the patient’s arrival. The team pre-decided on who is to do what tasks.
The ambulance crew arrive with the patient on a spinal board. The crew hand over the patient, a 42 year old male who was intoxicated with alcohol and overdosed on analgesics, had been involved in a high-speed police chase and sped off the road overturning his car and going through the windscreen. The patient had recently discovered that his wife was having an affair and this was the suspected cause of his actions. The police awaited outside the resuscitation department.
The patient was semi conscious maintaining his own airway. The registrar took the medical lead advising calmly who to do what. The anaesthetist took the management of the airway, a nurse provided comfort and reassurance to the patient whist taking observations. Another nurse cut the patients clothes off him and covered him with sheets.
The protocol used for patients involved in trauma is the Advanced Trauma Life Support (ATLS) system (American College of Surgeons 1997) which is a widely adopted management plan for trauma victims. Initial assessment consists of preparation, a primary survey, resuscitation, secondary survey and definitive care phase which is the ongoing management of trauma. Because the ATLS involves medical and nursing staff, they encourage inter-professional learning. This occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care’ (DH 2007). Most A&E departments use the ATLS protocols (Etherington 2003) as this system of managing the severely injured has now become part of best practice (Royal College of Surgeons 2000).
The registrar and the nurses all appeared highly familiar with ATLS protocol and a primary survey, secondary survey followed by definitive care phase was carried out systemically and smoothly. The team anticipated each others actions and care management resulted in the patient being able to maintain his own airway, breathing and circulation.
Other team members that became involved in the care management of this patient included the radiographer, lab technicians and the police. The nurses liaised with all these people and acted as a mediator of communication between the team. This reinforces Drach-Zahavy and Dagans’ (2002) concept of ‘glue function’ as it is nurses who maintain the holistic overview of the care given to the patient by all members of the inter-professional team.
It is worth noting that these examples are comparatively different in relation to the time of day they occurred, the teams that attended, and the age and presentation of the patients. These factors will be taken into consideration during discussion of the two examples.
Inter-professional team working
Nurses are obliged to adhere to the NMC Code which in relation to team working, clearly states that nurses must work effectively as part of a team and respect the skills, expertise and contributions of colleagues (NMC 2008). The importance of inter-professional working has been emphasised in a succession of government white papers addressing care (Hewison 2004) which call for more team working, extended roles for professionals and the removal of hindrances to collaboration (DH 2000a/b, 2004, 2005).
During a critical care emergency, effective teamwork, prioritising and speed of care delivery may mean the difference between life and death (Denton and Giddins 2009). National Patient Safety Agency (NPSA 2008) and National Institute for Health and Clinical Excellence (NICE 2007) agree that healthcare professionals are required to be able to respond appropriately in emergency situations. This entails an up-to-date knowledge of current evidence-based resuscitation guidelines (Resuscitation Council 2005, 2006) and the need for a team approach to care management of acutely ill individuals (Denton and Giddins 2009).
An exploration of inter-professional team working in a resuscitation area will now follow, using the above examples to appraise the importance of inter-professional collaboration. Teams and team effectiveness will be discussed as this is essential in identifying the mechanisms of teamwork involved in patient management and safety (Salas, Rosen and King 2007).
The DH (2005) recognise that outcomes of health care services are a product of teamwork and, the use of the word ‘team’ is a broad spectrum term aimed to include all healthcare professionals working inter-professionally. Mohrman et al., (1995) definition includes individuals who work together to deliver services for which they are mutually accountable and, integrating with one another is included among the responsibilities of each member. Leathard (1994) depicts inter-professional practice to refer to people with distinct disciplinary training, working together making different yet complementary contributions to patient focused care. The philosophy of care in the local A&E department incorporates these definitions stating; ‘professionals aim to promote team spirit with support to each other and encourage relations with other disciplines’ (Trust A&E nursing philosophy 2008).
Salas, Rosen and King (2007) suggest effective teams have several unique characteristics including: a dynamic social interaction with significant interdependencies, a discrete lifespan, a distributed expertise, clearly assigned roles and responsibilities, and shared common values and beliefs (Wiles and Robinson 1994). These characteristics require goal directedness, communication and flexibility between members (Webster 2002).
From these definitions, it is apparent that in healthcare a common and vital feature in teamwork is shared values and goals (Salas, Rosen and King 2007, Wiles and Robinson 1994). This serves as the teams focus point and appears to be at the pinnacle of what members strive towards. In example 1, shared values and goals are evident in the ALS protocols that the team followed. However, individuals roles were not clearly recognised and the team did not seem to be familiar with one-another.
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In example 2, the team again demonstrated shared values and goals by following agreed protocols (ATLS). This was further demonstrated in how the team interacted with each other and anticipated one-another’s actions. Pre-agreed tasks were organised by the team and they demonstrated mutual understanding of one-another’s roles. When members of trauma teams are given pre-assigned roles, they can perform a practice known as ‘horizontal organisation’ which refers to the ability of performing several interventions simultaneously (Patient 2007 and Cole 2004). Taking on pre-agreed roles and responsibilities can influence patient outcomes, limiting resuscitation times and lowering mortality rates (Lomas and Goodall 1994).
Salas, Rosen and King (2007) advise teams take time to develop a discipline of pre-brief where the team clarifies the goals, roles and performance strategies required. Example 2 demonstrates how, ‘this preparation is proven to amplify performance levels when functioning under stressful conditions’ (Inzana et al., 1996 cited in Salas, Rosen and King 2007).
A team approach in resuscitation has proved highly effective in reducing mortality rates (Walsh and Kent 2000). However, evidence suggests that human factors such as poor communication and lack of understanding of team member’s roles can breakdown team effectiveness leading to poor patient safety. (Xyrichis and Ream 2008, Atwal and Caldwell 2006). In relation to example 1, there were many team members present; nobody knew clearly who was who. To understand what makes an effective team, barriers inter-professional teams’ face and what can be done to overcome these obstacles shall be explored.
Barriers to Inter-professional team working
We have established that emergency care management involves many professionals each with their own discipline, knowledge and skills. Due to this diversity, professionals may have limited knowledge of each others’ roles and so undervalue the contribution of care delivered to patients, making inter-professional team working difficult (Spry 2006). Also, the way which individuals work together depends greatly on personalities and individual compatibility (Webster 2002). If personalities clash, this is a barrier to team effectiveness. In example 2, the team were familiar with one another and had evidently worked together in many trauma care situations as they seemed to trust and respect each other. This team were on their 3rd consecutive night shift working together therefore they had built a rapport with each other.
Similarly in Cole and Crichton’s (2006) study exploring the culture of a trauma team in relation to influencing human factors, many respondents described an amity and familiarity. They argued that teams work when people know their roles, have the required technical expertise and are knowledgeable about trauma. Cole and Crichton (2006) interviewed a consultant team leader who reports; ‘you can have the most gruesome scenario where you have a new surgical SHO and a new anaesthetic SHO, no-one knows each other and it’s atrocious!’ Teams made up of individuals who are familiar with each other work with greater efficacy than teams composed of strangers (Guzzo and Dickson 1996 cited in Cole and Crichton 2006). This report illustrates the challenges that team unfamiliarity poses.
In Cole and Crichton’s (2006) study, focused ethnography was used to explore the culture of a trauma team in a teaching hospital. Many ethnographic studies focus on a distinct problem amongst a small group. This method is appropriate when focussing on the meanings of individual’s customs and behaviours in the environment in which they are occurring (Savage 2000). Six periods of observation of trauma teams attending trauma calls was undertaken followed by 11 semi-structured interviews with purposively chosen key personnel. Their findings are based on the trauma teams working in one hospital; therefore this study is quite narrow. Cole and Crichton acknowledge that this method of study can be criticized for producing only one snapshot in time, potentially reducing its credibility. Taking these limitations into account, I believe their findings could be used to inform best practice where if the opportunity existed teams could be facilitated to practice working together. This would allow members to become familiar with each others personalities and roles.
Teams operating within an emergency medicine context face complex, dynamic and high-stress environments (Salas, Rosen and King 2007). However Denton and Giddins (2009) suggest staff in these areas become experienced in managing emergencies, know each others roles and have developed close team-working skills. Example 2 shows evidence to support this. Conversely, in example 1, the team seemed disjointed and nobody seemed to know each other. They assembled for the resuscitation but a lack of role perception hindered the team’s ability to work effectively together. Research into inter-professional team working and resuscitation attempts is limited (Denton and Giddins 2009). However, a small study of cardiopulmonary resuscitation conducted in a trust hospital by Meerabeau and Page (1999) found that, although team members of a resuscitation attempt may have a common goal (to resuscitate the patient) and some of the attributes associated with effective teams, many features may not be present. These features encompass regular interaction and clear roles as their evidence concludes, CPR teams generally did not work together nor practice their skills together. These findings support Cole and Crichton’s (2006) results and could be applicable to example 1 indicating that; although CPR teams trained specifically to react in CPR situations, factors such as regular interaction and clear roles influence team effectiveness.
If integrated inter-professional working is to become a reality, it is fundamental that people have opportunities to work closely together to build up personal relationships and understand others roles (Hewison 2004). Professional education needs to play a vital part in supporting this (Webster 2002). The DH actively encouraged initiatives in the NHS and in higher education institutions to encourage greater role awareness amongst health professionals and support effective team working (DH 2007, 2004a, 2000b). This allows team members to devise precise expectations of their team mates’ actions and requirements during high-stress work episodes (Salas, Rosen and King 2007). This is a logical solution but like Salas, Rosen and King (2007) note, teams come together for a discrete lifespan and depend upon who is on duty and time of day. Consequently having opportunities for developing personal relationships and understanding each others roles becomes a challenge.
A lack of specialist skills required to manage the care of critically ill patients is a potential barrier to delivering effective team care as this could escalate into inter-professional conflict. This is when nurses’ skills and doctors’ expectations of these skills differed (Tippins 2005). This barrier highlights the relevance of the ATLS training. Patient (2007) confirms that individuals who have undertaken the ATLS course claim they have gained an insight into each others’ roles and resultantly, can communicate with one another better (Hadfield-Law 1994).
The number of staff available varies between departments and is influenced by time of day (Etherington 2003). Example 1 took place on a busy Saturday morning and the department was bustling with staff. The team that attended to the patient was large and appeared disorganised. There were 11 members to this team, 4 of which were students who were perhaps encouraged to attend and observe the situation. The team that attended the patient in example 2 was comparatively smaller and appeared more organised. In an article by Tippins (2005) exploring nurses experiences of managing critical illness in an A&E department, one nurse describes how the nature of the experiences depended on the size and dynamics of a team: ‘Because it was such a big trauma, there were so many people there, actually you feel it’s not managed very well because there were so many people. It was just a bit chaotic really’. This example along with example 1 demonstrates that large numbers of people can make inter-professional working difficult.
The ideal number of team members in a resuscitation team is uncertain (Patient 2007). Etherington (2003) reinforces that effective teamwork is possible with just 3 people present providing leadership, trust and collaboration are achieved. Relating back to example 2, leadership, trust and collaboration was evident. There was also a strong awareness of roles and task distribution as opposed to example 1 where the team appeared to gather in an unorganised fashion. These examples demonstrate that the size of a team does not reflect quality. It is influencing factors such as role perception, communication and good leadership that make an effective team.
Within inter-professional teams individuals also need emotional intelligence to work effectively with colleagues and patients (Mc Callin and Bamford 2007). According to Goleman (1998), someone with high emotional intelligence is aware of emotions and how to regulate them and use this data to guide their thinking and actions (Faugier and Woolnough 2002). Self-awareness, social awareness and social skill are central to emotional intelligence. This is the heart of effective teamwork and influences excellence and job satisfaction (Mc Callin and Bamford 2007). The team in example 2 displayed emotional intelligence in their interactions amongst each other and the patient. For example, the registrar and the nurses constantly communicated with the patient recognising his distress. Team members also displayed ‘horizontal organization’ demonstrating their awareness and anticipation of one another’s roles and task allocation.
Breakdown in communication has been highlighted a root cause of serious incidents (National Patient Safety Agency 2006) and trauma resuscitations are especially vulnerable. Heavy workload and constantly changing staff can inhibit communication between team members and so affect adversely patient outcomes for example; medication errors or amputation of wrong limbs (Lynch and Cole 2006). Salas, Rosen and King (2007) highlight how communication often breaks down in the inherently stressful nature of responding to crises which can consequently result in clinical errors during decision making. Paradoxically, this is when communication needs to be at its finest (Haire 1998).
Many examples of high-quality nursing practice in managing critically ill patients involve good communication skills between staff, patients and relatives (Tippins 2005). Good communication begins and ends with self (Dickensen-Hazard and Root 2000). This relates back to the concept of emotional intelligence and awareness where every person, particularly the leader, should have a clear picture of self, of what is valued and believed and how that blends with the organisation served. Overall, clear, precise and direct channels of communication need to be in place to enhance patient outcome, team functioning (Haire 1998), patient safety and quality care.
Leadership
The concept of inter-professional team working and the barriers that hinder team effectiveness has been discussed. Now an analysis on team leadership will follow. Leadership is defined as a particular form of selected behaviour that manages team activity and develops team and individual performance (Lynch and Cole 2006). There is a strong focus on leadership within the health service as a resource for delivering quality care and treatment. This is noted in the NHS plan (DH 2000b) which states: ‘Delivering the plan’s radical change programme will require first class leaders at all levels of NHS.’ By having visible leaders at all levels contributes to setting high standards and amending errors efficiently. Consequently this contributes to maintaining a safe environment.
A resuscitation team needs a visible leader who has the knowledge and communication skills to direct team members (Etherington 2003). In relation to example 1, there was no immediate visible leader who took the task of preparing the team. Only later did the consultant take the lead. As suggested earlier, resuscitation teams are effective when team members adopt specific, pre-agreed roles, which can be carried out simultaneously. The consultant was unable to prepare the team as he arrived only seconds prior to the patient.
In the A&E department, effective leadership is of prime importance due to the fast paced nature of the environment, which lends potential for staff to feel threatened by the perceived chaos. The leader needs to foster an environment where care delivery has some structure, and staff have guidance and security (Cook and Holt 2000). This role of team leader is pivotal for the effective functioning of the team (Cole and Crichton 2006).
The consultant in example 1 and the registrar in example 2 were the identified team leaders. There are few recommendations made about the education necessary to become a team leader other than experience and seniority. The Royal College of Surgeons (2000) report that the team leader should be experienced in emergency management from either an emergency, intensive care or surgical specialty and have completed an ATLS course (Cole and Crichton 2006, American College of Surgeons 1997). From observation of leadership in the local resuscitation department, it appears that the most senior team member takes the lead.
Etherington (2003) argues that many A&E nurses perform the leader role as well as their medical colleagues. Meanwhile, Gilligan et al., (2005) argue that in many emergency departments A&E nurses do not assume a lead role in advanced resuscitation. Their study investigated whether emergency nurses with previous ALS training provided good team leadership in a simulated cardiac arrest situation concluding that, ALS trained nurses performed equally as well as ALS trained emergency Senior House Officers (SHOs). This study was conducted at five emergency departments. All participants went through the same scenario. Participants included 20 ALS trained nurses, 19 ALS trained emergency SHOs, and 18 emergency SHOs without formal ALS training. The overall mean score for doctors without ALS training was 69.5%, compared with 72.3% for ALS trained doctors and 73.7% for ALS trained nurses. The evidence drawn from Gilligan et al., (2005) suggests it may be
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