In this article by Dr Rosalyn Chaloner, Case Manager at Medical Protection, elements of teamwork (collaboration, communication and teaching and learning) will be discussed and each of these elements will be considered as they relate to the health care sector.
Acting as a team and collaborating are skills which are often overlooked in clinical training despite their vital importance in managing a patient’s health. If we act as separate entities, treatment may be replicated, or unnecessary additional procedures may be done when they may have been performed during another procedure. Simple mistakes may turn into much graver ones if they are not identified and corrected.
Take for example a patient having an operation. Before the operation can take place, the patient should be examined by the surgeon and then the anaesthetist. Furthermore, if the patient has other co-morbidities, a physician may need to assess the patient pre-operatively. The patient should be monitored before the surgery by the nursing team to ensure the patient has the optimal vital information for surgery to occur. This information regarding the patient’s blood pressure, pulse etc. may be used by the anaesthetist if complications occur. Blood samples may be taken and tested by laboratory staff and may be reviewed by a pathologist to ensure the necessary organs are functioning optimally. When the surgery eventually occurs, the surgeon will be in the lead and work with the anaesthetist with the crucial assistance of the surgical assistants and nurses. After surgery, the patient needs to be transferred to a recovery ward, where intense monitoring takes place by recovery nursing staff together with the anaesthetist. Then the patient moves to either an intensive care unit or a ward where they are looked after by that unit’s staff and the surgeon or physician.
Even the most seemingly auxiliary task, such as counting swabs, is essential for the patient’s best outcome. Medical Protection are currently assisting Dr T, a general surgeon, with a matter involving a retained swab, where post an incisional hernia repair, a swab was unfortunately left inside the patient’s abdomen. Dr T relied on the surgical nurse to count the swabs used and ensure the correct number of swabs were accounted for at the end of the surgery. Unfortunately, there seems to have been no one double checking this nurse’s work or assisting her, and a swab was left in the patient’s abdomen for three months, leading to the patient having to be treated for severe abdominal sepsis. We were initially assisting Dr T with a request for records but now this matter has escalated into a claim against both Dr T and the hospital in question.
It should never be forgotten that all clinical staff involved in a patient’s care are human and can make mistakes which are unintentional. Therefore, in order to minimise the risks and negative consequences, it is best that every clinical member of the team involved understands what operation was performed on the patient and what the expected major complications of the surgery could be. It is also imperative that the recovery, ICU, high care and ward staff know how to operate any post-operative drains or monitoring devices to prevent complications, or at least promptly identify a complication so that action can be taken immediately to prevent negative outcomes. In other words, adequate academic and practical training of all members of the clinical team is crucial to ensure patient safety.
In a separate matter, both an anaesthetist and a general surgeon are being assisted by Medical Protection where the surgical drainage bag was not activated post a right endarterectomy. This led to resuscitation of the patient becoming required and further surgery being necessary after a haematoma formed on the patient’s neck which compressed the patient’s airway.
Intertwined in collaboration is good communication. If communication is lacking or is not clear, mistakes may be made despite our best intentions. Suppose you are an inexperienced nurse who works in the recovery ward. Is it reasonable to expect you to know how to deal with patients who have had a large variety of surgeries, each one with different complications and different equipment which may be used after the surgery, which need to be managed precisely to ensure good patient outcomes?
Even in larger hospitals, where recovery teams may be split up and only treat one or two medical specialities, there still may be new equipment used that needs to be learnt about or different surgical techniques used rather than the ones that the nurses have become comfortable with over the years
Teaching and learning
In treating patients, all assumptions must go out the window regarding what someone in the team does or does not know. Ego, while being useful in creating the confidence needed to perform risky procedures, should also be minimised. No one should be above being taught something, even if they think they have all the knowledge necessary in that specific instance.
All practitioners should be open to teaching the colleagues who are part of their clinical team Naturally, this teaching and learning exercise would be in the best interests of the patient. We need to understand that learning is and will always be constant, especially in the healthcare sector. A professor or consultant will have a lot of specialised knowledge and others may still have wisdom to impart on them, from a medical student to a hospital porter.
The HPCSA Booklet 1 concerning general ethical guidelines, acknowledges the above under section 8 paragraph 8.1.in explaining the duties that health care professionals have to themselves regarding their knowledge and skills:
“8.1.2 Acknowledge the limits of their professional knowledge and competence.”
In an ideal world, a conversation should be had with all team members involved about what will be done with a particular patient, why and how, what complications to look out for and feedback from the team should be received in a welcoming manner regarding the proposed treatment plan and how to improve it. It is recognised that this is easier said than done realistically.
In alignment with the above, the HPCSA’s Booklet 1 states the following with regards to working with colleagues under paragraph 6.2:
“Healthcare practitioners should:
6.2.1 Work with and respect other health- professionals in pursuit of the best healthcare possible for all patients.
6.2.2 Not discriminate against colleagues, including but not limited to healthcare practitioners applying for posts, because of their views of their race, culture, ethnicity, social status, lifestyle, perceived economic worth, age, gender, disability, communicable disease status, sexual orientation, religious or spiritual beliefs, or any condition of vulnerability.”
While in the HPCSA’s Booklet 2: Ethical and Professional rules of the health professions of South Africa, under Annexure 6 the Medical and Dental Professions Board Rules of Conduct states the following, also relating to practising with colleagues:
“Performance of professional acts by medical practitioner or medical specialist
1. A medical practitioner or medical specialist –
(b) shall not fail to communicate and cooperate with medical practitioners, medical specialists and other health practitioners in the diagnosis and treatment of a patient;”
Treatment teams who work together and who teach and learn from each other, can protect the patient (and ultimately the members of the team, from a medicolegal perspective) from major mishaps, since one member of the team may identify a potential problem where another may not. We are all Health care practitioners are all fallible beings who can make mistakes and need each other to ensure that a molehill does not become an insurmountable mountain. This can greatly assist in the healthcare world where complexities can occur beyond our wildest imaginations and where charges as serious as culpable homicide are an unfortunate present-day reality.
In healthcare training, the importance of teamwork may often not be emphasized as strongly as it ought to be. It is commonly something that is learnt on the job once academic training is complete. Professional hierarchy is deeply ingrained in most healthcare centres. And what happens while those in power are unavailable? Every healthcare professional involved in a patient’s clinical care (and not just the most qualified person in the team) is important in ensuring that the patient thrives. While it may be impractical for the hierarchy to be altogether removed, as it is important to know where to turn to when a complicated patient presents or an issue needs to be resolved, if it is overemphasised it may lead to communication between team members being an impossibility. A culture of admitting mistakes and respect for every person’s viewpoint is necessary to remedy this.
The lack of time to practice teamwork is a recognised potential issue with this game plan. The question is if healthcare teams work together with better communication between all parties involved, will work not be done more effectively and efficiently? Will fewer mistakes be made? And ultimately, aren’t the long-established hierarchies in healthcare, where colleagues are scared to speak up, holding health care practitioners back from providing the best care available to patients?