Australasian Emergency Nursing Journal 20 (2017) 9297

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Australasian Emergency Nursing Journal

journal homepage: www.elsevier.com/locate/aenj

Research paper

An exploration of emergency nurses perceptions, attitudes and

experience of teamwork in the emergency department
Elise Grover a,b, , Joanne E. Porter c , Julia Morphet b
a
Peninsula Health, Frankston Hospital, Hastings Rd, Frankston, Victoria 3199, Australia
b
Monash University, Nursing and Midwifery, Peninsula Campus, McMahons Road, Frankston, Victoria 3199, Australia
c
Federation University Australia, Gippsland Campus, Northways Rd, Churchill, Victoria, 3841, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Teamwork may assist with increased levels of efciency and safety of patient care in the
Received 28 August 2016 emergency department (ED), with emergency nurses playing an indispensable role in this process.
Received in revised form 16 January 2017 Method: A descriptive, exploratory approach was used, drawing on principles from phenomenology
Accepted 17 January 2017
and symbolic interactionism. Convenience, purposive sampling was used in a major metropolitan ED.
Semi structured interviews were conducted, audio recorded, and transcribed verbatim. Transcripts were
Keywords:
analysed using thematic analysis.
Teamwork
Results: Three major themes emerged from the data. The rst theme when teamwork works supported
Emergency department
Emergency nurses
the notion that emergency nurses perceived teamwork as a positive and effective construct in four key
areas; resuscitation, simulation training, patient outcomes and staff satisfaction. The second theme team
support revealed that back up behaviour and leadership were critical elements of team effectiveness
within the study setting. The third theme no time for teamwork centred around periods when teamwork
practices failed due to various contributing factors including inadequate resources and skill mix.
Discussion: Outcomes of effective teamwork were valued by emergency nurses. Teamwork is about per-
formance, and requires a certain skill set not necessarily naturally possessed among emergency nurses.
Building a resilient team inclusive of strong leadership and communication skills is essential to being
able to withstand the challenging demands of the ED.
2017 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.

What is known? Introduction

Teamwork is essential for ED functionality to achieve its core
business efciently and effectively
Optimal teamwork practices contribute to reduced error rates,
increased patient safety, operational efciency and staff satisfac-
tion in the ED
What this paper adds?
Emergency nurses perceive teamwork as a positive construct
Emergency nurses intrinsically perform back up behaviour
Emergency nurses are not necessarily procient in crucial
non-technical skills such as leadership, communication and sit-
uational awareness during periods of increased demand
Teamwork practices have been identied as a vital strategy
in improving patient safety in healthcare and more specically
in the emergency department (ED) [13]. EDs rely heavily on
teams of healthcare professionals to carry out their operational
objectives and core business of delivering care to the acutely ill
and injured. The ED is recognised as a high-risk environment in
relation to service demand and potential for human error [2]. Team-
work has been identied as an effective strategy to reduce human
error, increase operational efciency, improve job satisfaction and
improve patient care [46]. However, few studies have considered
emergency nurses perspective of teamwork in the ED.
Background

During the 1990s and early 2000s medical errors and patient
Corresponding author at: Peninsula Health, Frankston Hospital, Hastings Rd, safety began to feature heavily within the literature. The land-
Frankston, Victoria 3199, Australia. mark report To Err is Human: Building a Safer Health System brought
E-mail address: Egrover@phcn.vic.gov.au (E. Grover). international attention to patient safety across healthcare [7]. One

http://dx.doi.org/10.1016/j.aenj.2017.01.003
1574-6267/ 2017 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
 E. Grover et al. / Australasian Emergency Nursing Journal 20 (2017) 9297
evidence-based approach to patient safety in healthcare can be
achieved by adhering to principles that promote team effectiveness
[3,8].
Military and aviation industries have researched and rened
teamwork practices for over 25 years, boasting standardised
teamwork training systems that have signicantly reduced error,
improved performance and saved lives and aircraft [9]. Parallels
can be drawn between aviation, military and emergency medicine,
with each requiring rapid decision making using incomplete infor-
mation, team orientated environments and with the signicant
potential for error causing harm or loss of life.
For the purpose of this paper a team was dened as comprising
of three critical elements: i) two or more individuals, ii) with a com-
mon objective or purpose, and iii) who are interdependent of one
another [2]. Optimal teamwork practices are reported in the litera-
ture to include features such as, maintenance of team structure and
climate, application of problem solving strategies, management of
workload and execution of plans, strong leadership, closed loop
communication, shared mental models, role delineation, back up
behaviour, situational awareness and adaptability [2,6,8].
While strong support for the benets of working in multi-
disciplinary teams in healthcare exists, the implementation of
teamwork training in the ED is reported to be complex and chal-
lenging [10,11]. The ED is a unique setting that has increased risks
associated with patient safety being a fast paced, high risk, and
at times unpredictable environment. It is therefore argued by the
authors, there is much to be gained through further exploration of
teamwork practices in the ED environment.
Aim
The aim of this research was to explore emergency nurses per-
ceptions, attitudes and experience of teamwork in the ED.
Methods
This project draws on phenomenology and symbolic interac-
tionism to explore the research questions; what are emergency
nurses perceptions and attitudes toward teamwork? and how
do emergency nurses experience teamwork? Phenomenology pur-
sues a key understanding, description and interpretation of human
behaviour and the meanings individuals attribute to their experi-
ences [12]. Symbolic interactionism theorises that an individuals
actions are inuenced by meanings derived or assigned from past
social interactions and modied by the interpretative process [13].
Symbolic interactionism is signicant to the participants past
encountering of teamwork, that may impact on how they currently
experience teamwork and function within a team today.
Setting
The study was set in a single major metropolitan Melbourne ED.
Ethics
Ethical approval was obtained from the hospital and university
Human Research Ethics Committees (HREC) prior to the com-
mencement of this study.
Sample
Purposive, convenience sampling was used to recruit study par-
ticipants. Inclusion criteria for this study involved all Registered
Nurses (RN) currently employed in the ED. Nurses employed in a
casual position were excluded.
93
Table 1
Interview Questions.
What is meant by the term teamwork for emergency nurses?
What are emergency nurses attitudes towards teamwork in the ED?
How do emergency nurses experience teamwork in their ED?
How is teamwork implemented and practiced in the ED?
Does teamwork improve professional satisfaction for emergency nurses?
ED = Emergency Department.
The study sample consisted of 12 RNs, including one Clinical
Resource Nurse (CRN), one Clinical Nurse Specialist (CNS), one RN
with a relevant post graduate qualication, one RN post gradu-
ate student, ve RNs who had completed a Transition to Specialty
Practice (TSP) program in the ED, and three RNs who had not com-
pleted any formal educational preparation for emergency nursing.
A CRN is an RN who works with Clinical Educators to provide on the
job training and clinical support to nurses, in this case, emergency
nurses. A CNS is an RN with specic post basic qualications or min-
imum of four years post registration experience, and is responsible
for advanced clinical nursing duties. A TSP is a structured program
for RNs designed to provide an introduction to specialist practice.
The TSP at the study setting is afliated with a major Melbourne
university, and successful completion of the program affords grad-
uates credit points towards a Graduate Diploma of Nursing.
Data collection
Semi structured individual interviews were chosen due to their
capacity to produce rich, insightful conversation exploring partici-
pants lived experience of teamwork in the ED. Interviews allowed
for core concepts to be discussed, while supporting the individual
to express their own ideas and reroute conversation in a subjective
manner in relation to their experience and understanding [14]. The
interviews took place in a meeting room designated by the Nurse
Manager at the study ED. The interview questions are presented in
Table 1. Interview duration ranged from 11 to 23 min.
Data analysis
Thematic analysis was used to analyse interview transcripts
subscribing to the process described by Braun and Clarke [15].
Table 2 outlines this process. Furthermore, the process of analysis
from quote to code to theme is demonstrated in Table 3.
Results
Demographic data
The nal data set consisted of interview transcripts from 12 RNs,
75% (n = 9) were female, and 25% (n = 3) were male. Over half (n = 7,
58%) the participants were aged 2329 years of age, 17% (n = 2) were
aged 3039 years of age, and 25% (n = 3) were 40 years and over.
The number of years nursing ranged from 2 to 15 years, while the
number of years working as an emergency nurse ranged from 1.5 to
12 years. On average the hours per week each nurse worked ranged
between 16 and 36 h, with the majority (n = 8) of participants work-
ing 32 h per week.
Interview themes
The emergency nurses described various examples considered
conducive to effective teamwork, as well as those considered bar-
riers or difculties associated with teamwork in the ED, the themes
and sub-themes are presented in Fig. 1.
94 E. Grover et al. / Australasian Emergency Nursing Journal 20 (2017) 9297

Table 2
Data Analysis Process.

Phase Example

1. Familiarisation with the data Repeated reading of transcripts

Repeated listening to interview audio recordings
2. Generation of codes Leadership
Communication ENABLERS
Positive attitudes
Negative attitudes
Busyness BARRIERS
High acuity patients
3. Search for themes Difcult to function in large team size
Attitudes can impact team functioning
Role allocation provides good team climate
4. Review of themes Researcher and supervisor meeting to discuss/debate themes
5. Dening and naming of themes When teamwork works
No time for teamwork
Team support
6. Collation of ideas and nal report An ideal teamwork climate in the ED
When teamwork fails
Back up behaviour
Teamwork training

ED = Emergency Department.

Table 3
Example of thematic analysis.

Quote Code Sub-theme Theme

If you do have a crappy day at work Enabler for effective teamwork Informal team building Team support
its okay. At the end of the shift its like,
alright lets go to the RSL, have a drink
and discuss it (Nurse 8).

RSL = Returned and Services.

League of Australia.

Fig. 1. Data Themes and Sub Themes.

When teamwork works
The interview transcripts revealed that there were periods
where teamwork worked well and conversely where teamwork
functioning broke down. During periods of perceived success-
ful teamwork functioning, participants reported feeling connected
with team members in working towards their mutual goals, being
able to better manage and execute patient care, with commu-
nication being central to this process. It was identied by the
participants that they had received no specic teamwork training
within the study ED. However, an ideal teamwork climate during
a shift was linked to positive perceptions of participants in rela-
tion to a number of key areas which formed the following sub
themes; (i) teamwork worked well in resuscitation, (ii) simulation
and training increased condence in team performance, (iii) team-
work may improve patient outcomes, and (iv) teamwork improves
job satisfaction.
(i) Teamwork Works Well in the Resuscitation Area
Numerous participants reported that teamwork worked well
in the resuscitation area. A number of key factors were identi-
ed to have contributed to or enhanced teamwork practices in
this area including higher nurse to patient ratio, more nurses with
post graduate qualication, and well dened, pre-allocated roles for
each team member. The resuscitation area consisted of at least one
post graduate trained nurse usually allocated to the nursing team
leader role. Management of stafng needs by means of redeploying
 E. Grover et al. / Australasian Emergency Nursing Journal 20 (2017) 9297
team members when not busy and recruiting staff when required
was reported as a quality of the resuscitation nursing team leader
unique to this area. Dened roles were allocated at the beginning of
the shift, which was considered a positive construct of teamwork
by nurses in the resuscitation area. Role allocation or delineation
was not described in any other clinical area.
(ii) Simulation Helps Team Performance
The participants that had participated in simulation training
agreed that simulation training increased condence in work-
ing as a team. A number of examples of training that involved
teamwork were identied by the participants to have improved
their condence in working as a cohesive and effective team. The
most frequently occurring examples were simulation education
and code grey training translating into increased condence in skill
execution when required in the clinical area. Code grey is an organi-
sational response to the prevention and management of clinical and
non-clinical aggression for the protection of staff and visitors [16].
The response is coordinated, clinically lead with security support to
address unarmed threats. I see a lot of teamwork come together when
we do a code grey. I think that has to do with a number of things we have
in place when a code grey is called (Nurse 12). Another example was
team management of clinical aggression training, reported by par-
ticipants to have increased condence in managing such patients
within an ideal team framework under challenging conditions.
(iii) Teamwork Improves Patient Outcomes
The majority of participants reported a perceived positive
impact on patient outcomes in relation to teamwork. Participants
frequently identied that patients needs could be met sooner with
a team approach, as the nature of emergency medicine frequently
required multiple tasks to be carried out simultaneously. Working
as a team you can get those jobs [assessment, vital signs, docu-
mentation, analgesia and pathology] done three times as fast and,
you know, the patient probably feels reassured more too. . . (Nurse
2). Management of workload and execution of planned care was
closely linked to optimal team functioning within the interview
transcripts, which participants linked to improved patient out-
comes.
(iv) Teamwork Increases Job Satisfaction
Emergency nurses frequently reported increased job satis-
faction and reduced stress when teamwork was present and
well-organized. Qualities such as a positive and compassionate
attitude, and a willingness to help, were identied as increasing
job satisfaction by means of making a shift more enjoyable. One
participant described . . .it [teamwork] just makes the shift run
smoother. If everyone is working together you dont feel as stressed
and anxious. Its a completely different shift if no ones helping anyone
(Nurse 11). Teamwork at times resulted in increased problem solv-
ing ability which participants described as satisfying. There were
no rst-hand accounts of teamwork reducing job satisfaction how-
ever there were reports that some team members did not like to
operate as a team, preferring to work independently. Further inves-
tigation is warranted to consider whether teamwork increases job
satisfaction in this sub-group.
Team support
Team support centred on being a good team player and working
towards achieving the goals of the team rather than an individ-
uals patient load. Assisting team members played an important
95
role in reducing stress levels particularly when competing demands
plagued one team member more than another. I think it [team-
work] works in a busy environment like emergency because if you are
caught up with something, you know there is somebody. . . who can
help out or take over. . . (Nurse 10). Back up behaviour, leadership
and role modelling, and in/formal team building formed the basis
of the overall theme team support.
(i) Back Up Behaviour
Back up behaviour featured heavily among the participants
descriptions of essential elements of effective teamwork, and was
widespread throughout the study ED. The participants described
back up behaviour throughout the interviews in terms of abil-
ity to predict when help was needed, and furthermore intervene
to provide assistance to team members. Hows my person doing
next door with their workload? (Nurse 5). Other examples of back
up behaviour occurred during the handover process where col-
leagues were able to identify potential missed care to be addressed.
Back up behaviour, when present, resulted in participants feeling
condent in delivering quality patient care. Opposing sentiments
were depicted when back up behaviour was not present which is
described in No time for teamwork.
(ii) Leadership and Role Modelling
Leadership and role modelling emerged frequently from within
the data as vital components of teamwork. There were many exam-
ples of how the team relied on a capable and inuential team leader
to coordinate patient ow as well as have an overview of all the
patients and each team members progress. Effective team leaders
were identied as being capable of delegating tasks and supporting
team members to perform unfamiliar skills. Leaders who fullled
participants expectations of their role checked in regularly with
team members and communicated team priorities. Conversely poor
leadership was identied as a burden to team functioning partic-
ularly in high acuity or complex patient scenarios whereby team
structure and support failed.
Role modelling provided emergency nurses with perspectives
and experience to improve their practice. Role modelling was
recalled by one nurse during a paediatric arrest, that although
overwhelming, she recalled as being a positive experience of ED
teamwork. The emergency nurse described feeling supported by a
senior staff member who stayed back to assist with her allocated
role. The participant went onto reect now its actually me as a
critical care nurse that is supporting other people. . . Its a good feeling
knowing that youve always got a back up (Nurse 10).
(iii) In/formal Team Building
There were a number of examples of informal team debrieng
including participants phoning each other or having a drink at a
local bar after a tough shift to talk through the events of the shift.
If you do have a crappy day at work its okay. At the end of the shift
its like, alright lets go to the RSL, have a drink and discuss it (Nurse
8). This type of behaviour fostered a team building atmosphere
among some participants who described going home feeling bet-
ter than they may otherwise have, and the actions showed people
cared. Having social relationships with team members increased
participants rapport with one another, and that was perceived as
improving professional relationships in the ED by some partici-
pants.
There was one example recalled by a participant who reported
feeling relieved despite a particularly challenging clinical situation,
in part due to a formal debrief. The debrief allowed the individual
96 E. Grover et al. / Australasian Emergency Nursing Journal 20 (2017) 9297
and the team to reect on the management and outcomes of the
patient, and their resultant feelings.
No time for teamwork
During busy periods, time pressures associated with ED func-
tioning lead to failure in key teamwork practices portrayed in
when teamwork works. Time pressures were reported as a result
of national targets, high numbers or rapid patient presentations,
unstable or challenging patients. I dont think anyone goes out not
to work as a team but if you are really stretched you just. . . nd it
[teamwork] difcult (Nurse 5).
Communication became increasingly difcult in situations of
heavy workload, in areas further away from the main work area,
and where alleged negative attitudes to teamwork were present.
Poor communication resulted in feelings of frustration due to
decreased awareness of team goals and potential delays in nursing
management.
Size of the team was also perceived to greatly impact teamwork.
. . .[Cubicles is a] very, very large area with a large amount of patients.
Just trying to get to six other staff members to try and support them
can be hard (Nurse 3). The team leader reportedly found it difcult
to provide adequate assistance to each team member while also
having a general overview of patients in this large clinical area.
The theme no time for teamwork emerged from participants
accounts of how failure in teamwork practices occurs in their ED,
largely as a consequence of i) inadequate skill mix or ii) inadequate
resources during periods of peak demand. These will be described
below.
(i) Inadequate Skill Mix
Emergency nurses identied poor skill mix as a key contributing
factor in the breakdown of team functioning in the ED. An insuf-
cient number of senior or experienced nursing team members was
repeatedly identied as a hindrance to uent teamwork. It was per-
ceived that less experienced emergency nurses needed more team
leader time and attention, and were unable to contribute to com-
plex patient care to the same degree as those with more years of
experience and/or post graduate training. While it was acknowl-
edged that experience only develops with time, the ratio of less to
more experienced emergency nurses impacted team functioning
signicantly and needed to be carefully balanced. The team leader
and most experienced staff on shift had a key role in supporting
staff and at times of increased patient activity and acuity, the level
of support needed was not always available to them.
(ii) Inadequate Resources
Participants frequently reported that a busy workload meant
they had no time to work collaboratively within their team. Numer-
ous participants described not being able to recruit assistance when
needed to manage their patient load optimally. Team members
at times worked individually feeling there was insufcient time
to communicate with those around them, or that communicating
their needs was futile knowing resources had been allocated else-
where. Theres been days when its just so busy that theres no time to
even talk to anyone because youre just focused on trying to see your
patients. . . (Nurse 8). Situations of demand exceeding resources
resulted in team members working as individuals rather than a
collaborative team. I think heavy workload can work against that
[teamwork] because youre trying to look after your own patch and
you havent got time to see if anyone needs a hand (Nurse 2).
At times disruptions to planned care as a result of code greys,
responding to patient deterioration, covering meal breaks and
patient transfers could result in participants experiencing inter-
ference with overall team operations. Such events were reported
to drain resources from one clinical area, rendering another area
understaffed and overstretched.
Discussion
Teamwork in the ED was generally perceived positively and was
valued by the participants. The ndings of this study support the
body of literature on teamwork, in that specic team behaviours
and characteristics, initially described in aviation and military
settings, can equally enhance teamwork functioning in the ED
environment [17]. Participants in the current study unanimously
reported the importance of skilled team leaders and excellent com-
munication among team members in order for teamwork to be
successful in the ED setting. Interestingly participants perceptions
of degree of capacity among colleagues to effectively lead and
communicate varied, particularly in times of increased stress or
pressure such as caring for patients requiring resuscitation, or dur-
ing periods of high workload.
Participants felt most supported and condent within the team
when the team leader was experienced, attentive, able to priori-
tise and coordinate team activities, while clearly and accurately
communicating among team members. Building a resilient team
inclusive of strong leadership and communication skills is essen-
tial to being able to withstand the demands of the present day ED
[11].
Participants in the current study frequently attributed effective
ED team functioning to the allocation of roles, quality skill mix,
and smaller, manageable team size. Similar concepts such as adap-
tive behaviour, mutual support, and job environment were used
in a number of studies to describe the ideal team climate for the
ED [6,11,17]. Back up behaviour emerged as a prominent theme
from the interviews. While back up behaviour appears within the
ED teamwork literature [2,8,9], participants placed great emphasis
on the critical nature in which back up behaviour supported team
members to perform their role and contributed to overall con-
dence in safe practice. Numerous participants valued knowing that
there was always someone more experienced to confer with, espe-
cially after-hours when less resources were available. Interestingly,
participants had received no formal training in back up behaviour,
it appeared to be a naturally occurring quality within the team.
During peak periods, teamwork was often said to breakdown,
resulting in feelings of increased stress and decreased staff sat-
isfaction. While identifying what constitutes effective teamwork
features broadly within the literature, fewer studies report sources
of teamwork breakdown or malfunction in the ED. Participants in
this study clearly identied a number of factors that resulted in
teamwork failure in their ED and the associated feelings this pro-
voked. The interviews revealed that during periods of increased
workload, team cohesion was lost, information exchange became
difcult and feelings of heightened pressure and isolation emerged.
During periods of increased demand, emergency nurses often
worked individually in a task focussed approach, at times unaware
of the workload of other team members, when arguably team-
work was most required. The current study reinforces that the core
principles of teamwork such as leadership, communication, mutual
support, situational awareness and monitoring, are not necessar-
ily naturally possessed qualities of emergency nurses, and specic
training is required to develop and execute these skills.
The interviews conducted in this study highlight that teamwork
is reliant on performance, and requires the execution of essential
non-technical skills. Strategies to augment teamwork skills among
emergency nurses are necessary for improved patient care and
safety. While research demonstrates the many and varied bene-
 E. Grover et al. / Australasian Emergency Nursing Journal 20 (2017) 9297
ts of teamwork training in the ED setting, there is no evidence
of how widespread such training has been implemented in the
Australian or international context. All participants in this current
study reported they had not participated in formal training specic
to ED teamwork. The ED environment provides endless opportu-
nities to facilitate team training, which would enhance teamwork
behaviours in future events.
Limitations of the study
The sample in this study represents the views of emergency
nurses in one Australian ED. While it is not possible to gener-
alise the ndings of this study, it does reinforce the evidence
related to the benets of teamwork in the ED. It is acknowledged
by the researchers that emergency nurses form part of an inter-
professional team, however it was beyond the scope of this study
to investigate different ED professional healthcare groups. Future
studies would benet from an inter-professional assessment of
team functioning more cognisant of the broader, inter-professional
ED team.
Implications for practice
Understanding the attitudes and perceptions of teamwork
among emergency nurses contributes to the growing body of evi-
dence supporting the advancement of teamwork practices in the
ED. Healthcare organisations have a responsibility to prioritise the
enhancement of team dynamics in EDs. Development and training
in specic teamwork skills such as leadership, communication, sit-
uational awareness monitoring, and teamwork systems should be
a strategic priority for ED service providers.
A key recommendation arising from this study is that teamwork
training should be implemented and is an essential component
of ED orientation and professional development agendas. Team-
work training should be inter-professional, to ensure ED staff across
each profession can function cohesively. Particular emphasis on key
areas identied in this study such as strategies that promote effec-
tive teamwork practice during times of increased demand warrant
further investigation.
Conclusion
This study highlights the importance of effective teamwork in
the ED, and some of the challenges in achieving optimal teamwork
performance. There are many factors that contribute to an ideal
teamwork climate in the ED including leadership, communication,
situational monitoring and awareness, and back up behaviour. For-
mal teamwork training of these non-technical skills needs to be
implemented as part of ED staff professional development.
An organised, effective teamwork climate in the ED has broad
implications for patient safety, quality of care, staff and patient sat-
isfaction. While much progress has been achieved, a philosophy
and culture of team training is an essential component of ED edu-
cation. Although it was identied that teamwork was, for the most
part, present and useful, it became apparent that when teamwork
was needed the most, it became difcult to sustain. The implica-
tions of teamwork failure in the ED include patient safety concerns
and reduced team morale. It is important that research into these
reported barriers are investigated further.
97
Conict of interest
There were no conicts of interest in the conduct of this study.
Funding
This study received no funding.
Acknowledgements
The authors gratefully acknowledge the emergency nurses who
volunteered their time and expertise to participate in this study.
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