You are on page 1of 15

Teamwork in resuscitation 1

Introduction Have you ever imagined a patient suffering from cardiac arrest and become loss of consciousness in front of you? Do you think you can handle it alone? Even though you are a well-experienced healthcare worker, the answer is certainly No. According to the American Heart Association (2003), an American will suffer an event of heart attack at about every 29 seconds. What the victim needed at once is probably the cardiopulmonary resuscitation (CPR) performed by a group of trained healthcare workers, and the soul of such process is definitely Teamwork. In this paper, we would firstly take a look on the concept of CPR process running at the Queen Mary Hospital (QMH) and do some literatures review on the teamwork among healthcare workers, and then try to explore the teamwork at the CPR among the QMH using a conceptual model. Thus, to identify some areas that needed to have improvement and finally give recommendations accordingly. A brief review of resuscitation process at the Queen Mary Hospital. QMH is one of the public hospitals in Hong Kong and as attached to the University of Hong Kong, it undertakes important teaching role and provides the most updated knowledge and skills to many healthcare professionals. Besides, QMH has won the Readers Digest Trusted Brands Gold Award from year 2007 to 2009, which means it is the most trustable public hospital for Hong Kong citizens (Readers Digest, 2010).

Teamwork in resuscitation 2

These are the reasons why QMH was selected as the target hospital in this paper. Plenty of protocols are prepared to guide the behaviors and works of staffs in QMH undergoing daily operations, in which the Operation Manual for In-hospital Resuscitation (2008) was drafted under the guideline of basic life support (BLS) and advanced cardiac life support (ACLS) produced by the American Heart Association. With reference to the operation manual, once the ward nurse found a patient arrested, she should call for help as well as check the airway, breathing and circulation of the patient immediately. If no breathings and heart rates are detected, all the nurses at the ward should initiate the resuscitation process. Different nurses have different roles and responsibilities, nurse A should perform the CPR with 30:2 chest compression to ventilation ratio by the help of bag-valve-mask device. Nurse B checks the vital signs like blood pressure, pulse and oxygen saturation of patient during the whole process and make record of time and actions taken because documentation is critical at the resuscitation process (Lyttle, 2000). The medical officer usually comes very soon after receiving the emergency call and takes in charge of the process. He would stand in front of patients head where can assess the whole body easily, maintain the airway and breathing by bagging patient with the oxygen mask device, read and interpret the electrocardiograms, make decision on what intravenous drugs should be used as well as the need of defibrillator to provide electric shocks correspondingly. Nurse C would

Teamwork in resuscitation 3

be responsible for setting the intravenous line, preparing and administering all the medications required. The health care assistants at ward can help clearing the environment and moving out other patients if possible. Sometimes, the on-call Anesthetist would come for insertion of endotracheal tube to protect airway and maintain breathing if required. Besides, due to the large physical-demanding workload of nurse A in doing the chest compression, all the nurses A, B and C would shift the works regularly during the resuscitation. In general, the whole dynamic process would last for at least 30 minutes, the patient will be certified dead if resuscitation failed. In contrast, if cardiopulmonary functions of patient resumed, the patient will be put on the mechanical ventilation and seek for further medical management. Literature review on teamwork among healthcare professionals The word Teamwork is defined by Xyrichis & Ream (2007) that two or more healthcare professionals with complementary skills, open communication and information sharing amongst members, as well as understanding of each professionals roles and having common goals. On the other hand, some researchers claimed teamwork in healthcare is not well defined in scientific understanding in research (Baker, 2006) and very little known about how to measure and improve teamwork in healthcare. (Thomas et al, 2004).

Teamwork in resuscitation 4

Therefore, the Institute of Medicine and others suggested taking the Crew Resource Management at aviation industry as references (Helmreich & Merrit, 1998; Odegrad 2000) to conduct more research on investigating the teamwork among healthcare providers. Their reasons was not just the two industries got similar features in the development of trauma resuscitation system, but also the aviation industry did have a longer history of measuring and improving teamwork to prevent and mitigate errors. Researchers Thomas, Sexton and Helmreich developed a tool called 10 behavioural makers in measuring the teamwork performance of healthcare workers in doing neonatal resuscitation at the year 2004, which is based on the Line Operations Safety Audit tool used in the aviation industry. Basically, all these 10 makers are observable, non-technical behaviors that contribute to the teamwork performance. The point is, coincidentally, almost all these behavioural markers matched a conceptual framework that drafted by Dickinson and Mclntyre at 1997. Dickinson and Mclntyre named this framework as the Teamwork Model (Appendix A) and it consists of three stages, which are the input, throughput and output and in which it can be divided into seven components. They are communication, team orientation, team leadership, monitoring, feedback, backup and lastly, coordination. This Teamwork Model will be used to explore the teamwork among the CPR process in this paper. The reason for not choosing the 10 behavioural makers is, as the

Teamwork in resuscitation 5

aim of this paper is not going to observe the teamwork in a real resuscitation scenario, but mainly to focus on the concept of teamwork at the whole CPR process. Exploring the teamwork in CPR process at QMH using the Teamwork Model. Fundamentally, communication is the major component of the CPR teamwork process, it means the exchange of information between all the team members (Dessler, 2001). It is the mechanism that linked all the other 6 components of the model throughout all the input, throughput and output stages. Many studies (Pilcher, 2009; Sargeant et al, 2008; Chang et al, 2009) showed the point that effective communication among healthcare workers can enhance the collaboration and finally promote better patient outcome, in other words which is the outcome of CPR here. Nevertheless, some researches showing that 70-80% medical errors are associated with poor team communication (Schaefer et al. 1994) and with reference to The American Association of Critical Care Nurses (2005), it also pointed out that about 60% medication errors were due to the mistakes in communication. Most importantly, Dagnone and Mcgraw (2008) showed that health workers do not possess essential communication skills facing cardiac arrest despite of completion of the ACLS course. Therefore, in order to have effective CPR, the enhancement of communication is of paramount importance. The input stage

Teamwork in resuscitation 6

This consists of two components at the same level and both are inter-related. The first component is team orientation, according to Dickinson and Mclntyre (1997), it means the attitudes of members have toward one another, self-awareness and group cohesiveness towards team task. Obviously, in the CPR process, the team goal of all members is to save somebodys life. However, there are various attitudes among the team members, as the existence of medical domination in the career culture (Pilcher, 2009) and nurses inputs in decision making during collaboration are not always received in the team (Thomas et al, 2003), doctors are tend to be more satisfied in CPR care than nurses in achieving the team goal. Furthermore, as such CPR team at QMH formed with an ad-hoc structure, which means a structure of purposeful combined cognitive and behavioral activity that accomplished serially under time constraint, with little or no chance of revision (Mendonca et al, 2007), the group cohesiveness is certainly not as strong as other pre-formed teams. Team leadership is another component, this is classified as the direction and structure by formal leaders as well as by the other group members in achievement of goals (Larson & Lafasto, 1989). In the CPR process, leadership is easily found at the doctor in charge, who makes decision of interventions clearly and directly based on the patients condition. Besides, the leadership style is apparently transactional, which is more task oriented (Eeden et al, 2008), and also autocratic (Vilert, 2006), which is

Teamwork in resuscitation 7

stronger in direct commanding and transfer of information, and thus promote the team performance in and effectiveness of the CPR process. Therefore, in order to maximize the force in the input stage, the team orientation, especially the group cohesion should be further improved. The throughput Stage Here comes to the second stage. Basically, monitoring is the first step, which has a direct link to the next step in this stage and the component of the output stage respectively. Bateman & Snell (2010) states that monitoring is an essential step for

leaders to control all the works in unit against units goals and plans. In the CPR process, actually all the team members do have monitoring every procedure they performing. For instance, doctor would monitor the overall picture of the patient, different nurses would monitor the corresponding drug effect after giving the intravenous medication, the effect of chest compression as shown on the electrocardiogram monitor, all the vital signs of patient, as well as the environmental safety. The step of monitoring is extremely crucial, as any mistakes made would certainly cause irreversible and fatal harm to patient consequently. Feedback and Backup are the second step follow monitoring in this stage that linked together of same importance. By Dessler (2001), feedback is defined as the receivers response to the message that was actually received in the process, which is an

Teamwork in resuscitation 8

on-going step making the CPR process more dynamic and functional. For example, the nurse reported to the doctor that there is a drop in the blood pressure, the doctor will prescribe drugs to boost up it accordingly. After the nurse has administered that drug, she can report to the doctor whats the effect and doctor can take actions correspondingly. Feedback here is regarded as the flow of information through the communication process among all the team members. Backup, according to Dickinson and McIntyre (1997), is to assist the performance of other team members, and that one who assists must know the skills in the task, and willing to provide help. There are two good examples in the CPR process. One is the inter-change of different nurses roles due to physical burden in doing chest compression. Another one is the help of the on call anesthetist in inserting the endotracheal tube rather than done by the doctor in charge himself. Therefore, the backup system is well developed. The output stage Last but not least, coordination is the unique component in this stage. It refers to the overall team performance and Yeatts & Hyten (1998) defined it as the act of performing two or three steps of a work in a proper order. A study conducted by Marzooq and Lyneham (2009) pointed out that the knowledge and skills of healthcare workers on ACLS is crucial to make more smooth coordination during resuscitation.

Teamwork in resuscitation 9

Also, it showed some nurses can only poorly recall the CPR knowledge because of the complexity of CPR tasks. What they suggested was institutions should provide standardized, periodic and structured training on ACLS to healthcare employees and evaluate it regularly. Recommendations Based on what observed, in order to promote the teamwork in the resuscitation process in QMH, the concept of self-managed team (SMT) of CPR can be introduced. Self-managed team is a group of employees, usually 5-15, who are responsible for managing and performing technical tasks in deliver goods or services to customers. (Yeatts & Hyten, 1998) and they are high in autonomy, identity and have authority to make decision concerning other matters for the group (Cohen et al, 1997). Similar concepts like the code team (Lyttle, 2000) in other countries, which a well-formed resuscitation team will be called to a scenario and completely takeover the whole process when incident happened. The first reason of introducing self managed CPR team is it can improve the team orientation. Self-empowered and self-willed SMT team members can ultimately lead to stronger focus on team goal (Hensey, 2000), this can improve the attitudes, especially nurses, towards the team goal. Also, SMT can further enhance the group cohesion as it is a well self formed and managed team rather than an ad-hoc.

Teamwork in resuscitation 10

Secondly, SMT can have positive influence on the communication and coordination among members (Yeatts & Hyten, 1998). Thus, it can bring many advantages in making more effective team performance to enhance the CPR outcome. Lastly, as SMT can choose own members and self-evaluate team performance (Bateman & Snell, 2010), specific training on ACLS can be conducted and evaluated systematically. Besides, Allcock and Wilson (1975) showed, many health professionals feeling anxious during resuscitation, this would certainly cause negative effect on doing CPR. If the team can choose members who are confident and competent in emergency management, the CPR outcome would be promoted directly. As a sum up, the idea of self-managed CPR team can improve the communication, team orientation as well as the coordination components of the Teamwork model efficiently and it is worth to take in further consideration. Conclusion Conclusively, after exploring the teamwork of resuscitation process in QMH, several areas, like communication, team orientation and coordination, are identified and needed further enhancement, the concept of self managed CPR team is therefore recommended. Things are easier said than done, due to the complexity the public health system and the difficulties in allocation of health service resources, the concept of self-managed CPR team must need further systematic and in-depth consideration.

Teamwork in resuscitation 11

References American Association of Critical Nurses (2005), Standards for Establishing and Sustaining Healthy Work Environments. AACN, Columbia. Allcock, M., Wilson, S. (1975) Code 66! From Anxious Amateurs to Smooth-working code team. Nursing 75, November. Baker D.P., Day R. & Salas E. (2006), Teamwork as an essential component of high-reliability organizations. Health Service Research, 41(4), 1576-1598 Bateman, T.S. & Snell, S.A. (2010), Management: Leading & Collaborating in a Competitive World (9th ed.), McGraw-Hill: London. Chang, W.Y., Ma J.C., Chiu, H.T., Lin K.C. & Lee, P.H. (2009), Job satisfaction and perceptions of quality of patient care, collaboration and teamwork in acute care hospitals. Journal of Advanced Nursing 65(9), 1946-1955. Cohen, S.G., Chang, L., Ledford, G.E., (1997) A hierarchical construct of self-management leadership and its relationship to quality of work life and perceived work group effectiveness. Personnel Psychology. Dagnone, J.D., Mcgraw, R. C., Pulling, C. A. & Patteson, A. K., (2008), Interprofessional resuscitation rounds: a teamwork approach to ACLS education. Medical Teacher, 30, e49-e54. Dessler, G. (2001), Management: Leading People and Organizations in the 21st

Teamwork in resuscitation 12

Century (2nd ed.), Prentice Hall. Dickinson T.L., Mclntyre, R.M. (1997), A conceptual framework for teamwork measurement. In: Brannick M.T., Salas, E., Prince C, eds. Team performance assessment and measurement. Mahwah, New Jersey: Lawrence Erlbaum, p.19-44 Eeden, R. V., Cilliers, F., Deventer, V. V. (2008), Leadership styles and associated personality traits: Support for the conceptualization of transactional and transformational leadership. South African Journal of Psychology, 38(2), pp.253-267. Helmreich, R.L. & Merritt, A.C. (1998), Culture at work in aviation and medicine: National, organizational and professional influences, Brookfield, VT: Ashgate. Hensey, M. (2000) Self-managed teams: readiness test. Journal of Management in engineering, April 2000. Larson, C.E., & LaFasto, F. M. J. (1989), Teamwork: What must go right/ what can go wrong. Newbury Park, CA: Sage. Lyttle, V. (2000), Before the code team arrives: Your Role, Nursing 2000, Vol 30, no. 10. Marzooq, H., Lynecham, J. (2009) Cardiopulmonary resuscitation knowledge among

Teamwork in resuscitation 13

nurses working in Bahrain. International Journal of Nursing Practice, 15, 294-302. Mendonca, D., Jefferson, T., Harrald, J. (2007), Collaborative Adhocracies and mix-and match technologies in emergency management. Communication of the Ach, March, Vol.50, No.3. Odegard, S. (2000), Safety management in civil aviation: A useful method for improved safety in medical care? Safety Science Monitor, 4(1), 1-12. Pilcher, T. (2009), Collaboration and teamwork in critical care. British Association of Critical Care Nurse, Nursing in Critical care, vol. 14 no. 2.. Readers Digest (2010), Retrieved from http://www.rdasiatrustedbrands.com/2009/main-home.html Resuscitation Subcommittee of Queen Mary Hospital (2008), Operation Manual for In-hospital Resuscitation (3rd ed.) Sargeant, J., Lonely, E. Murphy, G. (2008), Effective Interprofessional Teams: Contact is not enough to Build a Team. Journal of continuing education in the health professions, 28(4). Schaefer, H.G., Helmreich, R.L. & Scheideggar, D. (1994), Human factors and safety in emergency medicine. Resuscitation 28, 221-225. Stapleton, E. R. & Aufderheide, T. P. (2003), BLS for Healthcare Providers, American

Teamwork in resuscitation 14

Heart Association. Thomas, E.J., Sexton J.B. & Helmreich, R.L. (2004), Translating teamwork behaviours from the aviation to healthcare: development of behavioural markers for neonatal resuscitation. Qual Saf Health Care. Thomas, E.J., Sherwood G.D., Helmreich, R.L. (2003) Lessons from aviation: teamwork to improve Patient Safety. Nursing Economics, October, Vol.21, no.5. Vliert, E. V. D., (2006) Autocratic Leadership around the Globe: Do Climate and Wealth drive leadership culture? Journal of Cross-Cultural Psychology, 37;42 Xyrichis, A. & Ream, E. (2007), Teamwork: a concept analysis. Jounral of Advanced Nursing 61(2), 232-241. Yeatts, D.E. & Hyten C. (1998), High-Performing Self-managed Work Teams: A Comparison of Theory to Practice, Sage Publications.

Teamwork in resuscitation 15

Appendix A

Input Communication

Throughput Communication

Output Communication

Team Orientation Monitoring Team Leadership

Feedback Coordination Backup

Learning Loop

Teamwork Model

You might also like