The opening ceremony of smaccGOLD was a triumphant spectacle with a serious point to make.
Tribalism between various health care specialties
must be overcome
if we are going to provide truly
safe and outstanding care to our patients.
This was brought home to me recently through a rather unpleasant incident at work.
During the course of a normal shift, emergency nurses handover numerous patients to other wards as they are moved from the ED for admission. When the patient’s care requires it, an emergency nurse will accompany the patient to the ward or ICU to oversee their medical well being during the transfer. This procedure is carefully planned and timed, particularly when patients require more advanced care. Appropriately, such nurses have had to complete certain training before being allowed to facilitate such intra-hospital transfers.
After one such transfer, I was informed by a senior ED nurse that the receiving team had put in a complaint about my management of a patient during the transfer. This was the first time I’d received a complaint, and it caused me to look critically at my actions. After consultation and research I concluded that my actions were clinically acceptable, however it left me feeling uneasy. When I aired my feelings in the tearoom, I was startled to find a wealth of similar complaints had been issued by the same ward to numerous ED nurses. In fact, the consensus seemed to be “you’re not part of the team until you’ve had a complaint from (that department)”.
This dark side of tribalism exists all too often between hospital departments and it’s not just a specialty or profession issue. Whether in paediatrics or general medicine, whether a nurse or doctor, the belief that in your ‘zone’ care is better and more efficient is ubiquitous. Such ongoing antagonism over issues that are secondary to excellent care is harmful to our most vulnerable patients. If the staff on the ward had asked me at the time of handover, I could have explained my rationale for my actions and we could have had a fruitful discussion about future improvements. As it is, their submission of a formal complaint shut down any meaningful learning (on either side). The incident only served to widen the gap between our departments, reinforcing the ED perception that those nurses are ‘out to get us’.
The solidarity expressed by my ED colleagues was of course heartening, and highlights a positive element of tribalism – developing community amongst colleagues. I was, however, dispirited to discover such strong antagonism existed between our nursing departments. A quick search through the literature on this topic reveals that this corrosive form of tribalism is an ongoing problem between nursing specialties around the world. So what can be done to counter such acrimony?
Well, since communication lies at the heart of the issue, that is also where we should be looking for answers.
Pre-emptive contact about patients is always helpful, a heads-up; perhaps in the guise of eliciting advice on the best approach to a patient’s care during transfer. This is particularly helpful when the two persons communicating have never met each other – a situation that is very common in large clinical settings. Literature is available on good practice in handover and communication from the UK’s Royal College of nursing on theatre transfers but there exists little generic guidance for emergency departments. Some tools have been developed for transfers for specific conditions, but again it’s not practical to have guidance for every single medical condition.
One article that explores handovers between ICU and ED nurses concludes:
Collaborative work between the nursing teams in both departments would further enhance understanding of each others’ roles and expectations.
(From: “An exploration of the handover process of critically ill patients between nursing staff from the emergency department and the intensive care unit”. Abstract available here). People who know each others’ background and level of experience are less likely to find fault with one another. Inter-disciplinary simulation days are a wonderful way to break down some of the barriers between departments. Some hospitals can also arrange swaps – where an ED nurse might work in paediatrics for three months, in exchange of which the paeds nurse will work in ED. The uptake of such programmes has been disappointingly minimal in our hospital, but this does not negate the value of the concept.
I greatly respect the knowledge of the nurses I hand over to in various wards including ICU, paediatric, stroke and palliative specialties (to name just a few). ED nurses and doctors tend to be generalists, and I can see the value in learning from our more specialised colleagues in other departments. Instead of competing with other departments, let’s role-model a more mature and effective approach – one where we can build our tribe beyond the department and work together to maximise our patients’ well being.
- From EmergencyPedia: “The tribal nature of medicine”.
- “Tribal Leadership” by Dave Logan, John King, and Halee Fischer-Wright.
- Optimizing Physician-Nurse Communication in the Emergency Department: Strategies for Minimizing Diagnosis-related Errors.
- Patient Handoffs between Emergency Department and Inpatient Physicians: A Qualitative Study to Inform Standardization of Practice and Organization Theory.
- Supporting Communication in the Emergency Department
This post was brought to you with the kind collaboration of Dr Damian Roland. His editing and contributions have ensured a broader perspective and added some much-needed gravitas. Please visit his blog, Rolobot Rambles, if you want to be inspired and challenged. Errors in this post remain entirely my own.