Strategies used by nurses to promote teamwork in an emergency room

ABSTRACT

Objective

to analyze the strategies used by nurses to promote teamwork in a hospital emergency room.

Method

qualitative case study research with 20 nurses in the emergency unit of a university hospital in southern Brazil. Data were collected between June and September 2009 through participant observation and semi-structured interviews, and analyzed using thematic analysis.

Results

the strategies used by the nurses to promote teamwork in the emergency unit were articulating professional actions; establishing relationships of cooperation; building and maintaining friendly ties; and managing conflict.

Conclusion

nurses notably make the connections between the practices of the health teams and mediate the relationships established between health professionals to improve care practices.

Management; Emergency nursing; Nurse’s role; Emergency service, hospital; Patient care team

RESUMO

Objetivo

analisar as estratégias utilizadas por enfermeiros para promover o trabalho em equipe em um serviço de emergência.

Método

pesquisa qualitativa do tipo estudo de caso realizada com 20 enfermeiros do Serviço de Emergência de um Hospital Universitário da região Sul do Brasil. Os dados foram coletados entre junho e setembro de 2009 por meio de observação participante e entrevista semiestruturada e analisados pela técnica de análise temática.

Resultados

as estratégias utilizadas pelos enfermeiros para promover o trabalho em equipe foram: articulação das ações profissionais; estabelecimento de relações de cooperação; construção e manutenção de vínculos amistosos; e gerenciamento de conflitos.

Conclusão

o enfermeiro destaca-se por estabelecer conexões entre as ações realizadas pela equipe de saúde e mediar as relações entre os profissionais, visando ao desenvolvimento de melhores práticas assistenciais.

Gerência; Enfermagem em emergência; Papel do profissional de Enfermagem; Serviço hospitalar de emergência; Equipe de assistência ao paciente

RESUMEN

Objetivo

analizar las estrategias utilizadas por enfermeros para promover el trabajo en equipo en un servicio de urgencia en hospital.

Método

estudio cualitativo do tipo estudio de caso, realizado con 20 enfermeros del servicio de urgencias de un hospital universitario en el sur de Brasil. Los datos fueron recolectados entre junio y septiembre de 2009 a través de observación participante y entrevistas semiestructuradas y analizados mediante análisis temático.

Resultados

las estrategias de los enfermeros para promover el trabajo en equipo son: articulación de acciones profesionales, establecimiento de relaciones de cooperación, construcción y mantenimiento de los lazos de amistad, y gestión de conflictos.

Conclusión

el enfermero conecta las acciones de los profesionales de salud e intermedia las relaciones entre ellos con el fin de desarrollar mejores prácticas de cuidado.

Gerencia; Enfermería de urgencia; Rol de la enfermera; Servicio de urgencia en hospital; Grupo de atención al paciente

INTRODUCTION

In the emergency rooms, nurses are responsible for managing care, which involves the articulation of care and managerial activities such as prevision and provision of material resources, right-sizing staff, team leadership and coordination of the care process(¹-²). In view of these responsibilities, nurses play an essential role in the healthcare team, where they can create strategies that boost teamwork and organization in the care environment in order to provide quality care(³-⁴).

In the context of organizing nursing and healthcare practices, nurses are simultaneously members of the nursing and multi-disciplinary team, and assume a central role in the articulation and mediation of the tasks performed by both teams. In relation to the nursing team, it should be noted that nurses are legally responsible for coordinating and supervising the work of nursing technicians and aides. Consequently, nurses are expected to promote teamwork when managing patient care in emergency situations(²-⁵).

Care management is defined as the integration of care and management dimensions in the nursing practice(⁶-⁷). It is the result of a combination of hard technologies (equipment and procedures), soft-hard technologies (use of structured field-based knowledge, such as clinical medicine and epidemiology) and soft technologies (relationships, within the intersubjective space of the professional and the patient) that are exclusively based on the needs of patients(⁶-⁸). One of the most important soft technologies for managing care that is also inherent to teamwork is the coordination of work situations, where the agents create correlations and reveal the connections between the different interventions(⁹).

The connections between professional practices and knowledge are established through teamwork. Teamwork is the construction of consensus to reach objectives and expected results by all the professionals involved, and the best way to reach these objectives. Teamwork requires the connection of different work processes based on the interaction of the members and a mutual understanding and recognition of the authorities and knowledge^(10).

There are two teamwork modalities: grouped team, when there is an overlapping of actions and grouping of the members; and, integration team, when there is an articulation of the actions and interaction of the members. Communication between the members of the team is a common denominator of teamwork and it is the result of a reciprocal relationship between work and interaction(⁹). In this sense, teamwork that is cohesive and integrates the members from conception to execution is an efficient means to obtain high quality, safe care for patients(¹⁰-¹²).

However, teamwork within the context of the particularities of emergency hospital services is a challenge for nurses(¹¹,¹³-¹⁴). Even with the advancement of healthcare policies that establish the organization of an emergency care system in Brazil, hospital services continue to be the first point of entry of people in emergency situations(¹³-¹⁵). Overcrowding and continuous demands for care are almost constant in these sectors. Moreover, these problems generate an overload of work for these professionals and often compromise the quality of care and teamwork(¹⁴-¹⁵).

In light of this scenario, the guiding question for this study was: what strategies do nurses use to promote teamwork in an emergency room?

Therefore, the aim of this study is to analyze the strategies used by nurses to promote teamwork in an emergency room.

METHOD

Qualitative case study research(¹⁶) that is part of a master´s dissertation(¹⁷). The scenario was the emergency department of a university hospital in southern Brazil that provides patient care in the fields of clinical medicine, surgery, gynaecology and paediatrics. The service is divided into five areas according to the complexity of care: Reception with Risk Classification, Temporary Admissions Room (SIB), Observation Rooms (SO) 1 and 2, Vascular Unit (UV), Semi-intensive Care (SI) and Paediatric Unit (UP).

Data were collected between June and September 2009 by means of participant observation and semi-structured interviews.

The participant observation technique enables the integration of the observer to the study group. Based on this interaction, the researcher can capture the viewpoint of individuals from “inside” the case study by participating in the activities, situations and events that would otherwise be inaccessible(¹⁶). A script that targets the management work of these nurses and the relationship between the members of the nursing/healthcare team was used for these observations. A total of 40 observation periods were completed during all the shifts and days of the week, resulting in almost 90 hours of observation. The information collected during these observations was entered into a field journal.

During the interviews, the nurses were asked about the strategies they use to promote teamwork in the emergency service. A total of 20 interviews were conducted, recorded on an electronic device and subsequently transcribed. The selection of the participants was intentional, that is, among the nurses who agreed to participate in the research, and among the nurses who had worked for more than six months in the emergency service. This period was considered the minimum time required for the professionals to adapt to the routine work and team of the sector.

Both the number of observations and the number of interviews were established on the basis of data saturation in qualitative research. In case studies, this criterion is based on the repetition of information that allows the identification of convergences and a sequence between the evidence obtained through the collected data(¹⁶).

The empirical material was subjected to the technique of thematic content analysis, which has three steps: pre-analysis, material exploration and processing of the data, and inference and interpretation. In pre-analysis, the main idea of the collected material is organized and systematized according to the criteria of exhaustiveness, representativeness, homogeneity and relevance. In material exploration, the entries were used to transform raw data into text comprehension units and build empirical categories. The final stage consists of processing and interpreting the results based on literature(¹⁸). This process led to the category “Strategies of nurses to promote teamwork in a hospital emergency service”.

Research was approved by the Comitê de Ética em Pesquisa under number 09-151 and study participants signed an informed consent form. The observations and interviews were coded, respectively, with the acronym OBS and the letter E, followed by a number: OBS1, OBS2, ..., OBS40 and E1, E2, ..., E20.

RESULTS

The strategies employed by the nurses to promote teamwork in the emergency room are presented in four categories: articulating professional actions; establishing relationships of cooperation; building and maintaining friendly ties; and managing conflict.

Articulating professional actions

The work performed at an emergency room is configured as a collective process where the nurses are responsible for coordinating the professional actions that involve patient care in an emergency situation.

The nurses must have a broad vision of assistance that does not merely include the patient, but also the nursing staff, the care team, which in turn includes psychologists, physicians, pharmacists, dieticians, in order to provide care that is better suited to the user [...]. The nurses must try to connect nutrition with medicine, with pharmacy, with x-ray, [...] (E7).

Nurses are more involved with the organization, they run the show, they even have to organize things for other people to use the service. Nurses have to functionally organize the unit in order to work, which requires lots of contact with the medical team (E10).

[...] it depends a lot on nursing management, that task of helping the technicians to prioritize their activities [...] (E12) .

In order to manage care, nurses try to acquire an overall view of care that does not merely include the care provided to patients, but must also consider the nursing team and the healthcare team in the sense of coordinating the actions of each professional and seeking a more qualified care and dynamics in emergency work. The organizational role of nurses in the emergency service was well illustrated in the following statement, where the nurse refers to management as an immaterial task that is often invisible and involves the articulation of the actions of all the members of a healthcare team through communication.

It´s as if I weren’t doing anything, but I talk to one person, then to the other, I speak to them openly and they get everything done [...] (E 13) .

Establishing relationships of cooperation

Cooperative relationships are fundamental to teamwork, since study participants recognize that there is a relationship of dependency between the professional actions that are carried out in emergency services. Due to the overcrowding, for example, the nurses believe that the partnerships they have with the nursing technicians enable them to monitor the status and care demands of patients.

[...] the key is to work as a team, have a good relationship with the staff, because one depends on the other. As there’s so much overcrowding, if you don’t work as a team there are lots of patients you never get to see. The technicians are the eyes of nurses. There are things that we would never see if they did not notify us because of the overcrowding (E9) .

[...] I start my shift and take a general look to see if there are any serious cases, and ask the technicians to tell me if there are patients who are confused and disoriented so I can get to them first. The teamwork is fundamental, I would not manage otherwise (E13) .

[...] we have to create this partnership [...]. there has to be a partnership between the nurses, the physicians, the technicians for the work to get done (E19) .

Effective communication among the healthcare professionals is essential for a good work flow and integration in the emergency service. Analysis of the collected empirical material allowed the identification of teamwork for the integration modality during Reception with Risk Classification and the provision of care for high-risk patients in the emergency booth.

In the Reception with Risk Classification sector, given the overcrowding, in order to organize assistance and prioritize high-risk patients, the nurses asked the physicians directly about risk classification and/or asked them to prioritize certain patients, thus agreeing on conduct or actions that did not always comply with the institutional protocol.

[...] when our schedule is tight and the patients are arriving, then you have to pay attention, determine whether its urgent and take them to the booth, or classify the risk and schedule, which is when you have to interact with the medical team, and this is a really positive point for those of us who work in screening, because sometimes we can overlook things and the physicians can provide the backup (E9) .

When assisting high-risk patients in the emergency booth, the Vascular Unit (UV) and the Semi-intensive Care Unit (SI) moments of integrated teamwork were also detected, which favours efficient, quality patient care in emergency situations.

Patients who are suffering from convulsion are brought to the emergency booth by the Reception nurse. The UV/SI staff rush to assist them. The nurse proceeds with nasal catheterization and prepares the material for intravenous catheterization. A nursing technicians checks the vital signs and another removes the patient´s clothes. In the meantime, the physicians does the physician examination and the neurologist and a resident talk to the patient´s spouse to get information. The nurse has problems with the catheterization and asks the technician for help; in the second attempt, the nurse completes the procedure. All the procedures are quick, synchronized and precise (OBS25) .

In the UV/SI, the nurse is having trouble with an indwelling bladder catheter on a patient. He asks the physician for help, who promptly comes to his aid. They both talk and conclude that there could be problem with the passage of the catheter, and decide to use a smaller catheter. The nurse asks the nursing technicians for a new catheter and, this time, the physician tries to complete the procedure. He also has trouble with the procedure and asks the nursing technicians for the guide of the nasoenteral catheter. He introduces the guide into the bladder catheter and manages to complete the procedure. The nurse helps him fasten the catheter and the technician gathers the used material (OBS34) .

Building and maintaining friendly ties

The study participants believed that building and maintaining good interpersonal relationships with their colleagues was important to ensure efficient teamwork at the emergency room.

I try to get along with everyone, but there is always something you don´t like, or a colleague, [...] we have lots of problems with pharmacy, for example, and some call there and argue, I’ve done that a lot myself, but then I learned that that strategy does not work, you need that insight, fighting does not work, so let’s try another strategy (E1) .

[...] it’s always easier to work as a team when there is a more friendly relationship and partnership, it’s much better than having the medical team on one side, the nursing team on another side, and the social workers on the other side [...] (E12) .

Friendly, open relationships with dialogues that address topics beyond the hospital environment are common among nurses, physicians and nursing teams.

When the nurse passes the nursing station of the SO2, one of the technicians who is preparing medication asks him, “Have you learned how to beat Corinthians?” They laugh and talk about the match between Grêmio and Corinthians the previous night (OBS7) .

At the UV/SI, a physician and a nurse talk amicably as they perform their professional activities. They talk about their plans for the weekend and their upcoming holidays (OBS31) .

Managing conflicts

The work of nurses for the coordination of professional care management activities also requires the management of inherent conflicts and interpersonal relationships in healthcare and nursing.

[...] it’s managing the team, the interpersonal relationships, the conflicts that appear on a daily basis [...] (E2) .

[...] the nurses work with people [...] so they have to know how to work with these people, how to manage everything in a friendly manner, I think that’s the key to good nursing, knowing how to receive, how to identify the problems, there is no point thinking about quality patient care without thinking about the quality of the work of my employees (E7) .

Of all the emergency sectors, Reception with Risk Classification is where the conflicts of the nurses and the conflicts of the nurses with the physicians are most evident, as shown in the following statement:

[...] some conflicts are caused by screening, because each of us has a different judgement of the risk classification. Many of my nursing colleagues do not work in screening and have no idea of how it works. So, you end up giving priority to some patients, bringing more patients to the booth and lots of them get angry with you because you are bringing more work for them to do [...]. The same thing happens with the physicians, they say, “Oh, you classified this patient incorrectly, he didn’t need to come to the booth, he could have waited” [...] (E16) .

The conflicts between the nurses and physicians are caused by differences in relation to the level of risk attributed to patients during Reception. Some nurses, who are less familiar with the dynamics of this sector, view the high-risk patient taken to the emergency booth as extra work, which causes conflict between the Reception nurse and the UV/SI nurse.

DISCUSSION

Articulation is the soft technology that nurses use to integrate the actions of healthcare professionals, enhance teamwork and reinforce the cooperation of their work colleagues in relation to the provision of care in emergency services. Consequently, the focal point of nursing work is to mediate and negotiate the performance of work by means of dialogue and interaction with the healthcare and nursing staff to meet the needs of patients.

Articulation can be considered a skill that is acquired by nurses to coordinate care, which is one of the key care management practices performed by these professionals. Moreover, it is the result of the participation of nurses in all the stages of care, namely controlling, supervising and ensuring the resources required for the interventions and interconnecting the activities of healthcare and nursing professionals(⁷).

Requesting the help of nursing technicians to communicate clinical alterations in the status of patients is one of the conducts that reveals the nurse’s capacity to articulate. Through teamwork, nurses share the responsibility of providing care for clinically unstable patients, especially with the nursing technicians, who are responsible for notifying them of any changes or complications presented by the patients during the shift.

Although nurses stress the importance of teamwork, few moments of discussion and the joint creation of intervention plans among the professionals were observed in this study. This contradiction signals that the workers often perform their tasks within their field of expertise with the support of other professionals in their respective areas without discussing, planning or executing activities in an integrated and interdisciplinary manner.

Another point that was observed in the results was the misconception of teamwork. Some nurses perceive teamwork with a connotation that does not match the definition presented in literature. Although they believe they are articulating teamwork, some statements reveal that they are “tidying” the field for the work of other professionals and “fixing” things for them to perform their activities. It should be noted that teamwork is the relationship between work and the interaction of different technical agents in order to build a consensus in relation to objectives and results expected by the entire group, which uses communication to elaborate and execute a common project that observes the needs of healthcare users(⁹).

Teamwork in the integration modality was mainly observed in the Reception with Risk Classification sector and the assistance provided to high-risk patients in the emergency booth. During these interventions, the professionals conduct a collective work that includes cooperation, complicity and solidarity in order to provide the best possible care to patients and in a way that the understanding of all the members transcends historically hierarchical relationships in healthcare organizations. This finding converges with the results of a study on teamwork in prehospital care that reveals the presence of articulated actions for efficient and adequate care(¹⁹).

Building and maintaining friendly ties is also a strategy used by the professionals to enhance teamwork in the studied scenario. Teamwork requires social characteristics, such as collectivity, cooperation, commitment and responsibility, that promote interaction, harmony, mutual respect and communication among the health professionals(²⁰). However, these relationships alone do not lead to teamwork, which depends on interaction and the articulation of actions around the same care objective(⁹).

The presence of friendly ties and cooperation among professionals does not mean the absence of difficulties and moments of non-interaction, since collective arrangements required for the process and organization of healthcare and nursing work are prone to conflicts due to the very nature of this work. In this context, the management of conflicts is one of the most significant tasks that nurses must confront at work. In the hospital environment, nursing and healthcare teams are composed of professionals with different qualifications and origins and consequently present diverging values, attitudes and beliefs(¹²). These differences that are associated to the pursuit of margins of liberty and work spaces can generate personal issues and conflicts, which eventually affect the quality of patient care.

It is also important to acknowledge that structural problems, such as lack of human and material resources, a defective physical structure and other factors, can generate conflict, as reported in previous studies(⁵,¹⁵). Conflict resolution can positively influence the organization of work and favour the construction of common work objectives in the emergency service, thus intensifying the articulation among professionals and the practices of multi-professional teams.

CONCLUSION

This study led to the identification of four strategies used by nurses to promote teamwork in the context of an emergency room. These strategies are articulating professional actions, establishing relationships of cooperation, building and maintaining friendly ties, and managing conflict.

These strategies reinforce the work of nurses in the management of care and as articulators who are responsible for connecting the actions of healthcare professionals to mediate the established relationships and ensure the best care practices. Nurses are strategic agents in the promotion of teamwork in the emergency service, and they are capable of creating awareness and stimulating and articulating the team for the effective performance of integrated work.

The restrictions of this study are related to the generalization of the results and the composition of the study participants. The organizational policies and care practices of other emergency services can be different from those of the unit where the data were collected, which should be considered when addressing the applicability of the results in other contexts. Furthermore, this study only considered the standpoint of the nurses in relation to their actions for the promotion of teamwork in the emergency service. New studies can include the perspectives of other members of the healthcare team to expand the analysis and discussion of this popular subject.

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Publication Dates

• Publication in this collection
  2016

History

• Received
  10 Sept 2014
• Accepted
  24 Sept 2015