Teamwork in China - is it any different?

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Teamwork is something that is familiar to all emergency nurses. We work within multiple teams - our nursing team, daily shift team, cardiac arrest and trauma teams. We claim to be ‘good team members’ when we are interviewed, or when we are asked about the strengths of Emergency Department (ED) nurses. But how often do we reflect on the effectiveness of our teams, and how they can work together better?

I have recently been to China as part of a medical relief team. This was a small team made up of two ED consultants, two Orthopaedic consultants, a Plastics consultant, and myself. We also had a British advisor on Chinese healthcare, and were supported by two interpreters provided by the Chinese authorities. The medical team itself was pulled together within 48 hours, and although some had worked together on different projects this was the first time we had been together as a team - meeting for the first time the morning we travelled. Pulling together such a team at short notice, and expecting them to work effectively in a highly stressful situation is fraught with danger. Can a disparate team truly communicate, trust each other, identify a leader, and deal with conflict sufficiently to be effective in such a short time-frame? The experience highlighted much about teamwork, and how the lessons learnt from this experience can be transferred back to normal life.

At the most basic level a team needs a shared goal, or understanding (CHSRF, 2006). In going on a relief mission to a disaster struck country, there is little doubt about the goal of the team - to provide medical assistance in whatever way necessary. This is a very broad aim, and for this mission, there was a more specific interest in providing Orthopaedic and Plastics expertise. This goal was based on knowledge of previous earthquakes, and the types of patients seen. There was also a shared understanding that, dependant on the situation, all team members would be flexible in the delivery of care, and that all would work together to provide that care. Having a broad aim does not detract from the individual goals, and an effective team should be able to value both. This is not dissimilar to how we function within our trauma or cardiac arrest teams - pulled together at short notice, with little prior experience of working together, but with a shared understanding of the purpose of the team, and proposed outcomes. The team becomes dysfunctional if there are disparate goals, each specialty having their own agenda, with individuals not signing up to a shared vision. Members are not there to act as team members, but as specialists in their own right. In China, the ED specialists may have not seen any ‘emergency care’ and stepped away from their team responsibilities, to the detriment of surgical activity, and the teaching and learning opportunities available.

Some of these issues relate closely to understanding of individual roles and responsibilities within the team. Each individual member of the team will have a clear vision of their own role within the team, but this may not correlate with other team members, views of their role, or the role itself may alter throughout the task. Issues around burden of responsibility should be shared so that there is a joint sense of the impact of each individual within the team. In China, there was a sense of negotiation whilst the team identified the work needed, and the best way to deliver it. The surgeons went with a clear vision of undertaking operations, and providing expertise in this field. However, through the week their role had to change as the patient workload changed, with them taking on teaching/advisory roles, and establishing links for ongoing healthcare projects. We regularly reflected on events, on individual roles, and the impact of each member’s contribution within the team. This provided a basis for discussion and an opportunity to raise concerns, or areas of conflict that may have been detrimental to team goals. It allowed the team to mature, and evolve with events.

This issue clearly relates back to our own clinical teams. Each member of the trauma team, for example, may have a very clear vision of their own role, but this may not correlate with the team goal, or, more worryingly, a team member may have no individual interest in the ‘team’ goal. This issue will be more evident in teams brought together on an ad hoc basis, such as the trauma team, than in established nursing or departmental teams. In establishing a team then, it is essential that the team leader clarifies the purpose of the team, that each individual understands their role within it, and there is a forum to express conflicting opinions that does not effect the impact of the team.

In getting the job done, not only do we need collective thinking, and role clarity, but we must also want to work collaboratively, and trust the other team members (CHSRF, 2006). In a situation such as China, there was a sense that we all wanted to be there but, because of the situation and the fact we had been brought together at such short notice, we had to make these conditions explicit. Some of the work we did on the plane, and on our first night, was around setting standards, ensuring we each had the same vision in working together, but also in establishing trust. We had safety briefings, and discussed how we would behave as a group to reduce risk, e.g., carry phones with each others numbers, always know where each other were, etc., but we also talked openly about each person’s role, and how we trusted one another to complete the task. It is only in reflection since the trip that I can fully see the importance, and the benefit, of some of these conversations. One of the potential conflicts in teamwork is lack of trust in an individual’s ability within the task, or their understanding of risks involved, and this can be seen in our daily clinical work. In established teams there is general understanding of each other’s roles, and individual ability, providing a firm basis of trust, and knowledge of risk involved in delivering care. However, in larger multi-disciplinary teams, with little prior knowledge of skills or ability, team members may find it difficult to trust each other, slowing the work in hand, and potentially affecting outcomes. An effective team leader will account for this, both in establishing a team and their ‘rules’, but also in providing support for individual concerns or frustrations.

Leadership comes in many forms, and though there is often a deference toward experience and expertise, any team member may take on a leadership role, dependent on task need (Bristol Royal Infirmary Inquiry, 2001). That certainly was our experience in China, but can be seen in our daily work too. As we, as a team, identified our lead in someone who has extensive experience of disaster management, staff in our departments will look to the most senior nurse, or doctor to make decisions, and teams will defer to the most senior team member to lead resuscitations. Conflict may arise if there are a number of people who feel they should lead, or where there is lack of clear, identified lead within any group. This leads to multiple sources of communication, and divergent interests, with team members confused as to group priorities, and task direction. In contrast, effective leadership will provide a consistent vision, ensure each member’s role is clear and contribution valued, and act as a conduit for conflicting views. Leadership is not about making all the decisions, either, as the designated leader will not always be the specialist in certain aspects of a task. However, a good leader recognises the expertise within the group, and will readily refer to other team members whenever their expertise is required. This can be seen in a trauma team situation, where the team leader will ask for the expertise of different specialists involved throughout the episode of care, in order to achieve the team outcome.

All of these aspects of teamwork is underpinned by effective communication. Like teamwork, we all claim to be good communicators, and yet, when things go wrong, or complaints are made, it is primarily down to poor communication. Poor communication, or lack of confidence in speaking up, undermines team work, and achievement of goals (Leonard et al, 2004). In a fragile, and highly stressful environment such as our China experience, this communication is even more important. We were encouraged to speak openly about our concerns, our contributions, and our emotions, which created trust and understanding within the team, and really helped us to bond. I come back having worked with friends, with a different understanding of each of the members of that team, and a sense of loyalty to all that we achieved. This kind of working relationship is much more difficult to create in teams that are pulled together randomly, for example our trauma teams. But it is not impossible. When individuals understand the vision, and ethos of a specific team, have clarity in their role and their contribution to the whole, and know they can speak openly within the safety of the team, the outcomes can be great. And this is the case for not only small, disparate teams, but also much larger departmental teams who can work together to identify their own rules and support processes.

Teamwork is integral to our day-to-day life in the ED. We work together to make decisions, to implement care and achieve outcomes, often in highly stressful situations. The sense of achievement in working with a great team whether in the resuscitation room, in China, or in restructuring a service, is amazing, whilst an ineffectual team may affect patient outcomes, and leave individuals frustrated and disillusioned. It is only in spending a week with six other individuals in a potentially hazardous environment that some of the factors essential for effective teamwork become clear. These are nothing new, or innovative, and as such, it is everyone’s responsibility to establish teams with shared goals, good leadership, and open, honest communication, in a trusting, collaborative environment. Good luck.

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References 

1. Bristol Royal Infirmary Inquiry, 2001. Learning from Bristol: the report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984–1995. (Online) Bristol Royal Infirmary Inquiry. Available at http://www.bristol-inquiry.org.uk/index.htm. [Accessed 1st June, 2008].
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2. Canadian Health Services Research Foundation, 2006. Teamwork in Healthcare: Promoting Effective Teamwork in Healthcare in Canada. CHSRF, Ontario.
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3. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality & Safety in Healthcare. 2004;13(Suppl 1):i85–i90
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