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

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.

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

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

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

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

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

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).

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

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

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

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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