Interdisciplinary teamwork in the emergency department: how does it work?


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Leadership in shaping interdisciplinary teamwork of the emergency department

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Interdisciplinary teamwork in the emergency department: how does it work?

  1. 1. Ns. Arcellia Farosyah Putri, S.Kep., MSc Vignette I had a second night shift at emergency department when I was experiencing a very bad moment with my team. Our emergency team was consisted of seven nurses including one nurse who acted as nurses’ team leader, three emergency doctors and two radiographers. We had six areas to cover at emergency department: triage, trauma, non-trauma, pediatric, resuscitation and intermediate ward. Each nurse was appointed to in charge in each area by my head nurse team. Each nurse was responsible to take care of the patient within their covered area such as trauma, non- trauma and pediatric. They treat the patients based on the doctors’ instruction including laboratory and radiology check. At 1 in the morning, we missed two nurses in the team because one nurse was sick and the other one was disappeared during the shift, and so it was only five of us, including our nurse in charge. Moreover, because it was weekend, patients, who came to the emergency department, was increase significantly and some patients in resuscitation area were in a very bad condition, even my team leader had to lend a hand to help us. There were no coordination and lack of communication among team members that night. Everybody was busy with his or her own tasks. The only communication, which was run that night, was only in the term of giving instruction or hand over the patient. At this point, my team leader did not do anything. She only focused on completing the tasks to help us treating the patients. She was not trying to confront the misbehavior of my teammate disappearance, who put our team in worsen situation. She was also not trying to coordinate with the doctors. All she did was taking the doctors’ instructions again and again, and distribute them to us, her team members. We were so overwhelmed at that night, we try to covered other areas, where needed. Because of so much chaos happened, we failed to observe the patients adequately. There was a patient who came with complaint of abdominal pain and hard to micturition because we do not have enough human resources that night, we have to make priority based on patient’s urgency and this patient should wait a little longer. Time passed by, no one of us remembered about the patient. The last thing I knew that, he shouted out loud because of he was having the ureteral bleeding. He got very angry and threatened that he wanted to report and expose this negligence to the media.
  2. 2. Ns. Arcellia Farosyah Putri, S.Kep., MSc Interdisciplinary Teamwork in the Emergency Department: How Does It Work? Background Entering 20th century the complexities of current patient care requires specialized healthcare professionals and also requires them to work collaboratively in order to optimize patient care (Drinka and Clark, 2000; Hall and Weaver, 2001). This paper aims to address issues, which are emerged from interdisciplinary teamwork in the emergency department, as described on the vignette, and to provide possible solutions. This paper is divided into two areas of analysis as: First, teamwork and leadership issues in general and the second interdisciplinary teamwork system issues in the emergency department. Teamwork and Leadership In clinical practice, the health care provider often faces problems that are interrelated, complex and indefinite. Some problems are common and can be overcome easily with a regular problem solving. However, many complex problems are uncommon and finding the solution may cost time and effort (Drinka and Clark, 2000). According to Thompson (2008) there are three issues which are faced by healthcare professionals today: (1) preserving patient safety and quality, (2) lack of incentive, and (3) dealing with lack of human resource. Besides these top three issues, healthcare professionals today also face lack of relationships between academic and practice setting and lack of competent people in leadership areas (Richardson and Storr, 2010; Thompson, 2008). In the healthcare setting, it is important to remember that these complex issues can often result in patient errors, both directly and indirectly (Stelfox et al., 2006). Thus, being aware of the consequences, establishing an effective health care team and competent leadership may become the first steps to find a better complex solution (Drinka and Clark, 2000; Finn, Learmonth and Patrick, 2010). Department of Health of the United Kingdom (UK) in its publication, consistently believe that healthcare is provided by a team and improving teamwork can increase the safety of healthcare delivery (Department of Health, 2008a) (Department of Health, 2008b). The word ‘team’ is widely used to refer to all groups from any workplace or area (Finn, Learmonth and Patrick, 2010). In the healthcare setting, teamwork means “a
  3. 3. Ns. Arcellia Farosyah Putri, S.Kep., MSc group of individuals with diverse training and background who work together as an identified unit or system” (Drinka and Clark, 2000, p.6). According to Drinka and Clark (2000) performance of the team really depends on its members although organizational issues may also have the influence. Some factors such as members’ former experiences, personal and professional attributes often affect team’s achievements (Drinka and Clark, 2000; Firth-Cozens, 2001; Jenkins, Fallowfield and Poole, 2001; Leonard, Graham and Bonacum, 2004; Stelfox et al., 2006). Drinka and Clark (2000) also address that this former experience is not only in reference to experiences with the previous team but also interpersonal experiences with family, friends, cultural aspects and surroundings. As a result of this, each of the team members has different characteristics from one to another (Drinka and Clark, 2000). In the healthcare setting, these diversities emerge in various subspecialty departments or areas that may attract certain characteristics and people who share unique goals and values for delivering care (Drinka and Clark, 2000; Kalisch and Lee, 2013). Kalisch and Lee (2013) conducted a cross-sectional study to examine the variation of nursing teamwork components (trust, team orientation, backup, shared mental model [SMM] and team leadership) in different units: ICU, medical-surgical, intermediate, rehabilitation, pediatric, maternity, psychiatric, emergency department and perioperative. Total of 3,769 staffs participated in the study. They discovered that there were differences of nursing teamwork components in each unit. The level of trust (0.15, p<0.05), backup (0.18, p<0.05), and SMMs (0.15, p<0.01) among team members in the psychiatric ward was higher than in the ICU setting. Meanwhile, backup component was higher in perioperative areas (0.24, p<0.05) than other units. Although this research did not examine the relationship between the different characteristics of nursing teamwork in each unit and the patient outcome, but other researchers found a relationship between selected staff characteristic and teamwork performance. They believe that the impact of these teams and their characteristics determine how each team delivers care (Drinka and Clark, 2000; Manser, 2009; Bristowe et al., 2012). The final and the most critical component in an effective team performance is team leadership (Larson and LaFasto, 1989). Adair as cited in Bolden et al., (2003) recognized that there are three areas of the leader’s roles in teamwork (Action
  4. 4. Ns. Arcellia Farosyah Putri, S.Kep., MSc Centered Leadership Model) as: Task, team and individual area. Larson and LaFasto (1989) also identified three effective characteristics of leaders in a team: (1) Determine visions and plans: They must know the way something could and should be, (2) Create change: They influence their member to change as needed in order to achieve the team’s goals, and (3) Unleash individual talent: They explore and bring out team members’ contributing talent. These leader’s characteristics of Larson and LaFasto is basically included within three areas of Adair’s Action Centered Leadership Model. Moreover, Drinka and Clark (2000) presented leadership responsibility based on different types of team problems, which are: (1) common-simple problem, (2) uncommon-simple problem, (3) common-complex problem, and (4) uncommon- complex problem. When problems are simple, they occur frequently and they might have more than one solution. Thus, any team members can take the lead (informal leader), but the team should set rules that will help distribute the tasks. When problems are complex, any team member can take responsibility for alerting the team. However, the team should appointed a leader because a formal leader has more legitimacy with the administrative and negotiation side of organization (Drinka and Clark, 2000). Finally, based on leaders’ roles and responsibilities Drinka and Clark (2000, p.133), define the team leaders as someone who “moves the work of the team forward, directing the practice of healthcare toward the needs of the patient and the viability of the system, using uncommon sense in common situations”. Many researches indicate that the right person in a leadership role can add significant value to any collective effort of a team (Larson and LaFasto, 1989; Manser, 2009; Hunziker et al., 2011). Furthermore, leaders who are concerned and understand about different characteristics of their team members and its dynamics will result in better teamwork across units (Kalisch and Lee, 2013). A review which is conducted by Hunziker et al., (2011) revealed that despite technical skills, leadership skills also affect the outcome of a teamwork when performing Cardio-Pulmonary Resuscitation. Another study run by Bristowe et al., (2012) in clinical emergency settings explore inter-professional beliefs regarding effective teamwork. A qualitative study involving five groups, which consists of 5 to 7 respondents each from doctors, midwives, and healthcare assistants, found that
  5. 5. Ns. Arcellia Farosyah Putri, S.Kep., MSc effective teamwork rely on good leadership and staff experience. The importance of leadership in the pediatric area was described in randomized trial research conducted by Thomas et al., (2007) the result showed that lack of leadership and communication is estimated to contributed around 70% of perinatal deaths and injuries. In addition, there are many other researches that provide evidences in a relationship between poor leadership and teamwork with patient outcomes in the emergency area (Salas et al., 2008; Edelson and Litzinger, 2008; Hunziker et al., 2009). Interdisciplinary Teamwork System in the Emergency Department There are two key characteristics of the emergency department that should be remembered in relation to work culture and environment and how they may affect leadership and teamwork performance: (1) emergency department provides 24 hours and seven days care (Milbrett and Halm, 2009) and (2) the healthcare provider at the emergency department often deals with an uncertainty situation (Paley, 1996; Chisholm et al., 2000). These characteristics lead to other issues, as described below: 1. Twenty-four hours and seven days care As a result of this type of care providing, overcrowding in emergency department become a common issue from time to time (John and Lynn, 1990; Andrulis et al., 1991; Richardson, Asplin and Lowe, 2002; Fatovich and Hirsch, 2003; Moskop et al., 2009). However, the number of patients coming is imbalanced with the number of human resources that causes exhaustion among healthcare providers (Kilcoyne and Dowling, 2007). This exhaustion can cause cognitive and emotional strain that may impair effective individual teamwork behavior and leadership (Gevers et al., 2010). 2. Uncertainty situation Clinical area is an uncertain area and the emergency department is surely a place in the hospital where an uncertainty level is extremely high. Unpredictable patient and complex problems become the main features of the emergency department (Shirley and Langan-Fox, 1996). To answering these problems, it is required a complex solution from interdisciplinary healthcare team under effective leadership (Drinka and Clark, 2000). Drinka and Clark (2000) suggest that in complex clinical areas task distribution and problem solving process must included a team, which consists of interdisciplinary
  6. 6. Ns. Arcellia Farosyah Putri, S.Kep., MSc healthcare professional, to obtain optimum goals and prevent errors. Interdisciplinary team defines as “a team whose members from many professions work together closely and communicate frequently to optimize patient care” (Hall and Weaver, 2001, p.868). Moreover, Hall and Weaver (2001) explained there are six key concepts of interdisciplinary teamwork, which are sharing the burden of care, understanding equality in responsibilities and reciprocity, sharing a common goal, and trusting team members. Meanwhile, in the vignette, although there are healthcare professionals from several disciplines in the emergency area, but by the process they worked individually, lack of communication, which is by definition and concept, cannot be called interdisciplinary healthcare professional team. In emergency department, the healthcare professional such as doctors, nurses, etc. always assigned to a specific area for one duration of a shift to perform a specific purpose of caring, as a team (Fernandez et al., 2008). An experimental study was carried by Patel and Vinson (2005) in the emergency department to look at the difference of patient outcomes that were treated before and after team assignment system. The team consisted of interdisciplinary healthcare professional: 1 emergency physician, 2 nurses and 1 technician. The results of this study showed association of a team assignment system implementation with reduced percentage of patients who waited more than 3 hours for treatment 17.8% before and 11.8% after (absolute difference -6.0%; 95% confidence interval [CI] -4% to -8.1%), increased patient satisfaction 3.1%; 95%CI 1.0% to 5.3%), and improved coordination of care (absolute increase 3.6%; 95% CI 0.8% to 6.4%). This research has proved that the interdisciplinary team assignment system is effective to enhance patient outcomes, both directly and indirectly. Thus, pointing to the vignette problem of patient negligence, this type of team assignment system may become a possible solution. However, this type of assignment system (interdisciplinary team) can only be done when there are multiple physicians, nurses and technicians on duty at one shift (Patel and Vinson, 2005) and it is really difficult to be implemented in the real clinical setting due to several reasons such as high cost and its complexity (Drinka and Clark, 2000). In detail, Drinka and Clark (2000); Hall (2005) explained that one of the reasons why interdisciplinary teamwork is difficult to be implemented is because its
  7. 7. Ns. Arcellia Farosyah Putri, S.Kep., MSc complexity which is emerged from the nature of healthcare professional’s training and education cultures. Each discipline has different culture such as values, beliefs and attitudes. These cultures affect the effectiveness of interdisciplinary teamwork because each of healthcare professionals are trained to think critically only in their own area of expertise and they are not aware about other areas. But Salas et al., (2008) answered this challenge. They conducted a meta-analysis research to examine the relationship between team training interventions and team functioning. They found that team training had a moderate, positive effect on team functioning (ρ = 0.34; 10% CV = 0.34; 90% CV = 0.34). Although this study was conducted in groups that the members come from one type of discipline not interdisciplinary, but another authors believe that several skills such as group, communication, conflict resolution, leadership, and role blurring skills should be included in training and education content to help improving interdisciplinary teamwork (Hall and Weaver, 2001). Another possible solution to answering the complexity interaction among healthcare professionals is by conducting reflective practice (Jarvis, 1992). Healthcare professionals’ training, as has been said by Drinka and Clark, is individual based training which conducted repeatedly in practice area after a long time it becomes habit and more often makes healthcare professionals less aware about their surroundings including the other area of expertise besides their area. Reflective practice acts as their monitor to review possible things that have been missed during teamwork process so they can achieve a better outcome (Jarvis, 1992). In the emergency department, interdisciplinary teams often work under an unpredictable situation with limited time period, yet the task should be done rapidly and correctly, therefore an effective and strong leadership is needed (Rawlinson, 1990). Moreover, Drinka and Clark (2000) explained that interdisciplinary leadership consists of six components: environment, situation, leaders, team members, power and communication. They suggested that interdisciplinary leadership is about the roles that are played by each of the team members. Both leaders and team members must be aware of interchangeable roles among them depending on the environment and situation (Drinka and Clark, 2000).
  8. 8. Ns. Arcellia Farosyah Putri, S.Kep., MSc çèAcceptçè èRejectç Figure1. Essential Elements of Interdisciplinary Leadership (Drinka and Clark, 2000, p.107) Contrarily, on the vignette, the task distribution was detached based on profession not as an interdisciplinary team. Doctors’ role is apart from nurses’ team. Their role was always to give instruction of a treatment and act like a leader or coordinator of the team all the time, which according to Xyrichis and Ream (2008) is not the basic concept of interdisciplinary teamwork. Previous literature also showed that one of the key concepts of interdisciplinary teamwork is the existence of shared leadership based presenting problem (Drinka and Clark, 2000). However, other researchers argue that shared leadership based presenting problem can only be effectively implemented in chronic problems such as in the psychiatric area (Rosen and Callaly, 2005; Kalisch and Lee, 2013) and cancer (Dysvik and Furnes, 2012). In these situations, the leader can take turns among interdisciplinary team members depending on current patient problems emerged. But due to a life saving condition, the leadership that is conducted in the emergency department is a task-oriented situation. This means that the leadership process demands more specific distributing tasks, assigning work, and enforcing rules and procedures (Hunziker et al., 2011). Since the problems, which arise, in the emergency department are often urgent problems, the leader who leads the team in emergency condition should have all of the skills and capacities to perform life saving. According to the world health organization’s regulation every person, who has adequate competencies in performing life saving, is responsible to act. Referring to this regulation, in emergency condition, doctors or other persons, who have proven to have the best level of competency, will always be the team Environment Leaders: Formal and Informal Team Members: Followers/Peers Situation
  9. 9. Ns. Arcellia Farosyah Putri, S.Kep., MSc leader. In other words, there will never be a shared leadership in the life saving situation (World Health Organization, 2013). Nevertheless, not all patients who come to the emergency department have a life-threatening situation. In fact, only 40% of them are defined as a ‘true’ emergency (red triage), the rest are less emergency or not in emergency condition (Andrulis et al., 1991). Hence, Drinka and Clark (2000) suggested that it is important for a leader to understand the problems emerging in different situations and match them with appropriate team practice. There are four teamwork systems: (1) ad hoc/task group: consist of more than one discipline/department which working together on a specific issue and then disbands (2) a formal work group (un-disciplinary): consist of several people working together continuously from one discipline/department, (3) formal work group (multidisciplinary): consist of several people working together continuously from various disciplines/departments but individual identities more important than integrated diagnoses and do not work on team problems and (4) interactive team (interdisciplinary team): consist of more than one discipline/department, team goals for the patient and team, members are interdependent and allow collaboration. In addition, of four teamwork systems, Drinka and Clark (2000) added autonomous practice as a part of the system. Autonomous practice means that the leader requires team members to work individually and independently in one sub-area and decides quickly based on his/her knowledge to find appropriate solutions. Another leadership issue in this vignette is regarding the ‘hands-on’ of nurse’s head team. Overcrowding of the patients and lack of human resources forces the head team to lend a hand in the emergency. Effective leadership is linked with effective teamwork performance. Therefore, leaders who lend a hand in the emergency, presumably become a less effective leader. The distraction, caused by performing two different roles: team coordinating and patient caring, makes the achievement of both roles is not optimal. This situation, tends to suffer team performance and, at the end, the patient outcome (Hunziker et al., 2011). The last leadership issue, arising, in this vignette is about the interaction of the head team with the team members and how she addressed problems. According to Eagly and Johannesen-Schmidt (2001) women’s leadership style tends to have communal
  10. 10. Ns. Arcellia Farosyah Putri, S.Kep., MSc attributes, which means, they pay attention to people’s prosperity, act gently and sensitively. In the workplace setting, they usually speak tentatively, sometimes indecisively. Unfortunately, in a particular situation, which requires effective and immediate solution, as in the vignette, these characteristics of leadership bring more harm than good. There are two of the leader’s blind sides that can have a link with gender leadership. First is confronts behavioral process. “Leaders who are unwilling to confront and resolve issues associated with inadequate performance by team members” (Larson and LaFasto, 1989, p.136). Second is a never-ending line of tasks. “Leaders who take too many tasks for the team, who unquestioningly accept whatever tasks, are given them” (Larson and LaFasto, 1989, p.137). They will overload the team with tasks. These blind sides, apparently found more in women’s leadership style than men (Larson and LaFasto, 1989). On the vignette, the first blind side appeared when the head nurse did not do anything to confront a team member’s behavior that left the post without any explanation on the first day. Druskat and Wolff (2006) believe that there are two opposite effects when conducting confrontation to resolve an issue. Conducting confrontation towards a member who breaks the rules may have negative effects such as time consuming and emerging emotional issues both on the member and other team members. On the other hand, ignoring the behavioral problems may lead to a dysfunctional team and performance. The leader should know when and how to perform confrontation. Confront behavioral process, may become a potential solution, when it is carried out effectively (Druskat and Wolff, 2006). The second blind side appeared when the head nurse accepted any instruction from the doctor and not performing communication or coordination earlier to solve the problems. At the end of the day, the results from this chaos were ineffective team performance and patient complaints. An effective leader should know when exactly to postpone, to distribute and to stop the tasks’ path flow and re-arrange the strategy to solve the problem effectively and efficiently (Druskat and Wolff, 2006). Conclusion Interdisciplinary teamwork is not always applicable to solve emergency patients’ problems due to their various level of urgency. Moreover, there are many factors that should be considered when implementing this type of teamwork. Understand the
  11. 11. Ns. Arcellia Farosyah Putri, S.Kep., MSc contributing factors and know how to address them may provide a better teamwork performance, which as a result of this will also improve the patient outcome in the emergency department. Recommendation/Implication for Practice After reviewing literature and finding evidence that discuss teamwork and leadership issues in the healthcare setting, there are several recommendations that may help improving teamwork performance in the emergency setting specifically and in other healthcare contexts generally, where appropriate: 1. Overcoming lack of human resources and overcrowding patients Hospital managers should find an effective way to overcome these two ‘old’ problems of almost every area in the hospital, especially in the emergency department. System changing, this include revising patient’s path flow of the emergency department, is necessary to support the implementation of an effective team assignment system. 2. Matching team and task distribution based on the patient urgency In the emergency department not all the patients who come are in emergency situations (red triage). It is important to identify when, how, and what type of teamwork systems that should be conducted based on patients’ level of urgency. Interdisciplinary teamwork with shared leadership may not be appropriate for a true (red triage) emergency patient. 3. Conducting leadership/teamwork training program Working as a team is difficult and it is more difficult if the team members come from many disciplines. Leadership/teamwork training programs can minimize the gap among healthcare professionals and create better understanding among them. 4. Nurturing Self-Awareness Understanding the complex interaction among teamwork, leadership, and contributing factors is not enough. Healthcare professionals should nurture self-awareness through reflective learning to make sense those interactions within the team, decide the best patient centered solution and put it into practice.
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