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Australasian Emergency Nursing Journal: Elise Grover, Joanne E. Porter, Julia Morphet
Australasian Emergency Nursing Journal: Elise Grover, Joanne E. Porter, Julia Morphet
Research paper
a r t i c l e i n f o a b s t r a c t
Article history: Background: Teamwork may assist with increased levels of efciency and safety of patient care in the
Received 28 August 2016 emergency department (ED), with emergency nurses playing an indispensable role in this process.
Received in revised form 16 January 2017 Method: A descriptive, exploratory approach was used, drawing on principles from phenomenology
Accepted 17 January 2017
and symbolic interactionism. Convenience, purposive sampling was used in a major metropolitan ED.
Semi structured interviews were conducted, audio recorded, and transcribed verbatim. Transcripts were
Keywords:
analysed using thematic analysis.
Teamwork
Results: Three major themes emerged from the data. The rst theme when teamwork works supported
Emergency department
Emergency nurses
the notion that emergency nurses perceived teamwork as a positive and effective construct in four key
areas; resuscitation, simulation training, patient outcomes and staff satisfaction. The second theme team
support revealed that back up behaviour and leadership were critical elements of team effectiveness
within the study setting. The third theme no time for teamwork centred around periods when teamwork
practices failed due to various contributing factors including inadequate resources and skill mix.
Discussion: Outcomes of effective teamwork were valued by emergency nurses. Teamwork is about per-
formance, and requires a certain skill set not necessarily naturally possessed among emergency nurses.
Building a resilient team inclusive of strong leadership and communication skills is essential to being
able to withstand the challenging demands of the ED.
2017 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
Teamwork is essential for ED functionality to achieve its core Teamwork practices have been identied as a vital strategy
business efciently and effectively in improving patient safety in healthcare and more specically
Optimal teamwork practices contribute to reduced error rates, in the emergency department (ED) [13]. EDs rely heavily on
increased patient safety, operational efciency and staff satisfac- teams of healthcare professionals to carry out their operational
tion in the ED objectives and core business of delivering care to the acutely ill
and injured. The ED is recognised as a high-risk environment in
relation to service demand and potential for human error [2]. Team-
What this paper adds?
work has been identied as an effective strategy to reduce human
error, increase operational efciency, improve job satisfaction and
Emergency nurses perceive teamwork as a positive construct
improve patient care [46]. However, few studies have considered
Emergency nurses intrinsically perform back up behaviour
emergency nurses perspective of teamwork in the ED.
Emergency nurses are not necessarily procient in crucial
non-technical skills such as leadership, communication and sit-
uational awareness during periods of increased demand Background
During the 1990s and early 2000s medical errors and patient
Corresponding author at: Peninsula Health, Frankston Hospital, Hastings Rd, safety began to feature heavily within the literature. The land-
Frankston, Victoria 3199, Australia. mark report To Err is Human: Building a Safer Health System brought
E-mail address: Egrover@phcn.vic.gov.au (E. Grover). international attention to patient safety across healthcare [7]. One
http://dx.doi.org/10.1016/j.aenj.2017.01.003
1574-6267/ 2017 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
E. Grover et al. / Australasian Emergency Nursing Journal 20 (2017) 9297 93
Setting The nal data set consisted of interview transcripts from 12 RNs,
75% (n = 9) were female, and 25% (n = 3) were male. Over half (n = 7,
The study was set in a single major metropolitan Melbourne ED. 58%) the participants were aged 2329 years of age, 17% (n = 2) were
aged 3039 years of age, and 25% (n = 3) were 40 years and over.
Ethics The number of years nursing ranged from 2 to 15 years, while the
number of years working as an emergency nurse ranged from 1.5 to
Ethical approval was obtained from the hospital and university 12 years. On average the hours per week each nurse worked ranged
Human Research Ethics Committees (HREC) prior to the com- between 16 and 36 h, with the majority (n = 8) of participants work-
mencement of this study. ing 32 h per week.
Purposive, convenience sampling was used to recruit study par- The emergency nurses described various examples considered
ticipants. Inclusion criteria for this study involved all Registered conducive to effective teamwork, as well as those considered bar-
Nurses (RN) currently employed in the ED. Nurses employed in a riers or difculties associated with teamwork in the ED, the themes
casual position were excluded. and sub-themes are presented in Fig. 1.
94 E. Grover et al. / Australasian Emergency Nursing Journal 20 (2017) 9297
Table 2
Data Analysis Process.
Phase Example
ED = Emergency Department.
Table 3
Example of thematic analysis.
If you do have a crappy day at work Enabler for effective teamwork Informal team building Team support
its okay. At the end of the shift its like,
alright lets go to the RSL, have a drink
and discuss it (Nurse 8).
When teamwork works and training increased condence in team performance, (iii) team-
work may improve patient outcomes, and (iv) teamwork improves
The interview transcripts revealed that there were periods job satisfaction.
where teamwork worked well and conversely where teamwork
functioning broke down. During periods of perceived success- (i) Teamwork Works Well in the Resuscitation Area
ful teamwork functioning, participants reported feeling connected
with team members in working towards their mutual goals, being Numerous participants reported that teamwork worked well
able to better manage and execute patient care, with commu- in the resuscitation area. A number of key factors were identi-
nication being central to this process. It was identied by the ed to have contributed to or enhanced teamwork practices in
participants that they had received no specic teamwork training this area including higher nurse to patient ratio, more nurses with
within the study ED. However, an ideal teamwork climate during post graduate qualication, and well dened, pre-allocated roles for
a shift was linked to positive perceptions of participants in rela- each team member. The resuscitation area consisted of at least one
tion to a number of key areas which formed the following sub post graduate trained nurse usually allocated to the nursing team
themes; (i) teamwork worked well in resuscitation, (ii) simulation leader role. Management of stafng needs by means of redeploying
E. Grover et al. / Australasian Emergency Nursing Journal 20 (2017) 9297 95
team members when not busy and recruiting staff when required role in reducing stress levels particularly when competing demands
was reported as a quality of the resuscitation nursing team leader plagued one team member more than another. I think it [team-
unique to this area. Dened roles were allocated at the beginning of work] works in a busy environment like emergency because if you are
the shift, which was considered a positive construct of teamwork caught up with something, you know there is somebody. . . who can
by nurses in the resuscitation area. Role allocation or delineation help out or take over. . . (Nurse 10). Back up behaviour, leadership
was not described in any other clinical area. and role modelling, and in/formal team building formed the basis
of the overall theme team support.
(ii) Simulation Helps Team Performance
(i) Back Up Behaviour
The participants that had participated in simulation training
agreed that simulation training increased condence in work- Back up behaviour featured heavily among the participants
ing as a team. A number of examples of training that involved descriptions of essential elements of effective teamwork, and was
teamwork were identied by the participants to have improved widespread throughout the study ED. The participants described
their condence in working as a cohesive and effective team. The back up behaviour throughout the interviews in terms of abil-
most frequently occurring examples were simulation education ity to predict when help was needed, and furthermore intervene
and code grey training translating into increased condence in skill to provide assistance to team members. Hows my person doing
execution when required in the clinical area. Code grey is an organi- next door with their workload? (Nurse 5). Other examples of back
sational response to the prevention and management of clinical and up behaviour occurred during the handover process where col-
non-clinical aggression for the protection of staff and visitors [16]. leagues were able to identify potential missed care to be addressed.
The response is coordinated, clinically lead with security support to Back up behaviour, when present, resulted in participants feeling
address unarmed threats. I see a lot of teamwork come together when condent in delivering quality patient care. Opposing sentiments
we do a code grey. I think that has to do with a number of things we have were depicted when back up behaviour was not present which is
in place when a code grey is called (Nurse 12). Another example was described in No time for teamwork.
team management of clinical aggression training, reported by par-
ticipants to have increased condence in managing such patients (ii) Leadership and Role Modelling
within an ideal team framework under challenging conditions.
Leadership and role modelling emerged frequently from within
(iii) Teamwork Improves Patient Outcomes the data as vital components of teamwork. There were many exam-
ples of how the team relied on a capable and inuential team leader
The majority of participants reported a perceived positive to coordinate patient ow as well as have an overview of all the
impact on patient outcomes in relation to teamwork. Participants patients and each team members progress. Effective team leaders
frequently identied that patients needs could be met sooner with were identied as being capable of delegating tasks and supporting
a team approach, as the nature of emergency medicine frequently team members to perform unfamiliar skills. Leaders who fullled
required multiple tasks to be carried out simultaneously. Working participants expectations of their role checked in regularly with
as a team you can get those jobs [assessment, vital signs, docu- team members and communicated team priorities. Conversely poor
mentation, analgesia and pathology] done three times as fast and, leadership was identied as a burden to team functioning partic-
you know, the patient probably feels reassured more too. . . (Nurse ularly in high acuity or complex patient scenarios whereby team
2). Management of workload and execution of planned care was structure and support failed.
closely linked to optimal team functioning within the interview Role modelling provided emergency nurses with perspectives
transcripts, which participants linked to improved patient out- and experience to improve their practice. Role modelling was
comes. recalled by one nurse during a paediatric arrest, that although
overwhelming, she recalled as being a positive experience of ED
(iv) Teamwork Increases Job Satisfaction teamwork. The emergency nurse described feeling supported by a
senior staff member who stayed back to assist with her allocated
Emergency nurses frequently reported increased job satis- role. The participant went onto reect now its actually me as a
faction and reduced stress when teamwork was present and critical care nurse that is supporting other people. . . Its a good feeling
well-organized. Qualities such as a positive and compassionate knowing that youve always got a back up (Nurse 10).
attitude, and a willingness to help, were identied as increasing
job satisfaction by means of making a shift more enjoyable. One (iii) In/formal Team Building
participant described . . .it [teamwork] just makes the shift run
smoother. If everyone is working together you dont feel as stressed There were a number of examples of informal team debrieng
and anxious. Its a completely different shift if no ones helping anyone including participants phoning each other or having a drink at a
(Nurse 11). Teamwork at times resulted in increased problem solv- local bar after a tough shift to talk through the events of the shift.
ing ability which participants described as satisfying. There were If you do have a crappy day at work its okay. At the end of the shift
no rst-hand accounts of teamwork reducing job satisfaction how- its like, alright lets go to the RSL, have a drink and discuss it (Nurse
ever there were reports that some team members did not like to 8). This type of behaviour fostered a team building atmosphere
operate as a team, preferring to work independently. Further inves- among some participants who described going home feeling bet-
tigation is warranted to consider whether teamwork increases job ter than they may otherwise have, and the actions showed people
satisfaction in this sub-group. cared. Having social relationships with team members increased
participants rapport with one another, and that was perceived as
Team support improving professional relationships in the ED by some partici-
pants.
Team support centred on being a good team player and working There was one example recalled by a participant who reported
towards achieving the goals of the team rather than an individ- feeling relieved despite a particularly challenging clinical situation,
uals patient load. Assisting team members played an important in part due to a formal debrief. The debrief allowed the individual
96 E. Grover et al. / Australasian Emergency Nursing Journal 20 (2017) 9297
and the team to reect on the management and outcomes of the patient transfers could result in participants experiencing inter-
patient, and their resultant feelings. ference with overall team operations. Such events were reported
to drain resources from one clinical area, rendering another area
No time for teamwork understaffed and overstretched.
The sample in this study represents the views of emergency The authors gratefully acknowledge the emergency nurses who
nurses in one Australian ED. While it is not possible to gener- volunteered their time and expertise to participate in this study.
alise the ndings of this study, it does reinforce the evidence
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