Monday, May 14, 2001

Teamwork or Why Did You Come to Work Today?

Times are tough in our Emergency Departments and not likely to improve for a while. We’re all doing too much with too little, too many patients waiting too long for some portion of their care in too crowded spaces while too few professionals try to keep the patients "safe" and family and friends informed. Every winter, this past one included, the local and national press seems to discover just how crowded our EDs have become and just how stressed we who work in them feel.

Recent predictions of a worsening shortage of nurses trumpeted by the general press seem laughable to those of us who have been working in EDs that have had vacant nursing positions for more than two years. Overtime hours for our nursing staff, short-staffing and "coverage" by agency nurses in an effort to fill that gap just add to the stress. Emergency physician practices are seeing shrinking income for many reasons including insurers denying claims, even when submitted with a copy of the chart, because despite state level "prudent patient" laws and regulations if the insurer holds onto the money longer, they benefit from the "float" and perhaps you won’t appeal because of the cost in your time and billing expense. Reduced practice income translates into physicians working longer hours in order to maintain income or holding off adding an additional physician to the group, even though growth in patient volume may warrant it.

Most EDs in the country are staffed with hospital-employed nurses, clerical and technical personnel. Outside of the Northeast and academic health science center hospitals, most emergency physicians work for themselves or for a contract group that may staff one or hundreds of hospital EDs. It’s been said by some that, "Nurses run the ED, physicians just work there." Still others have pointed out, "Emergency Physicians enjoy a truly collaborative practice and this is what drew many of us into our field." What are you as the leader doing to support your entire team?

In 1994 I began working with the Institute for Healthcare Improvement Inter-disciplinary Professional Education Collaborative, and despite 19 years of emergency medicine experience as a resident and attending physician, I came to learn for the first time the true nature of an inter-disciplinary team and inter-disciplinary collaboration. Few readers will have the same opportunity, yet all of you reading this, practice collaboratively to some degree in your ED. How can you improve upon the collaboration—the interdisciplinary team—that currently exists for the benefit of both your patients and yourselves?

In my October 2000 column I urged cooperation with your ED nurse manager in refining the details of documentation, both physician and nursing, that would support appropriate billing of ambulatory payment classifications (APC) for hospital payment for ED services. More recently, we’ve all enhanced our assessment and management of pain for all patients, an effort that required collaboration among all ED staffers.

These opportunities for collaboration are a continuing reality in our professional lives and they provide the opportunity to go beyond bedside collaboration to a true inter-disciplinary team building effort in which mutual respect and support are the goals. These opportunities allow us to "walk a mile in the other’s moccasins" not so that we can learn what it takes to perform nursing duties, but rather so we learn how truly different and difficult those nursing duties are and therefore why we must partner with nurses.

Nursing is not practicing medicine and as a physician, you and I intelligent, well educated and medically trained as we may be simply do not know what goes on in both the training and acculturation of a nurse anymore than a nurse understands these same experiences and perspectives in a physician’s life. Oh, there are always exceptions: nurse-physician couples with exceptionally good communication skills and receptivity to one another’s viewpoint or the rare colleague who practiced as an emergency nurse before going to medical school and who now practices as an emergency physician. And while I won’t discuss it further, the same issues pertain among all specialized employment groups that work in your ED including clerical staff, tech staff, pharmacy staff, environmental services staff and others.

Step one to building an inter-disciplinary team is truly acknowledging nurse to physician and physician to nurse, out loud and in public, that neither truly understands the other’s training, practice culture, legal and regulatory concerns among many other issues. Why out loud and in public? Because once stated in this way, there’s no going back to the old way of doing business. Once stated this way, you’ve essentially agreed that you each must engage the other in addressing your issues because you’ve agreed that you need the other’s "take," i.e., viewpoint on whatever it is you’re addressing. From this foundation a new relationship can develop if you will work at it. Would alternative management structures help? Certainly, but ultimately success here rests on person-to-person relationship building. In the ED where care of patients is our agenda, building that effective relationship—the interdisciplinary team—must be on our agenda.

Ideally, the respective physician and nursing leaders should make the statement together and to a joint gathering, reinforcing the position by on subsequent occasions and individually, slowing the rush to complete a project until the other is engaged. For example, discussion at a physician staff meeting to start shifts 30 minutes earlier to facilitate morning commuting could bring up the comment from the meeting leader, "I’ve no problem with that, but perhaps we should engage the nurses before we commit to the change." Then engage in a meeting—not merely "on the fly"—the nurse manager, the evening or night shift charge nurse or both and staff nurses so as to get the widest range of opinion. Meeting with the physicians and nurses together is better, yet, but usually entails involving representatives of the groups rather than the whole staff.

Inter-disciplinary teamwork begins by acknowledging the expertise and necessity of the "other" and builds through engagement in progressively more complex problem solving. While in the main, physicians give treatment orders and nurses implement them, smooth operations in the ED come not only from each knowing their role, but also from successful, trust-building work that acknowledges one another’s unique expertise and culture. Achieving those successes in a structured, non-clinical setting will carry-over to the patient’s bedside.