Abstract
Emergencies that happen within a maternity center can happen from maternal and fetal complications. The outcomes of theses situations can be largely influenced by the efficiency of the teamwork between members of the healthcare team. The purpose of this paper is research strategies that enhance teamwork between two units of a maternity center. The problem preventing these two units from performing efficiently is that these two units do very different things and members of each unit do not comprehend what the other unit does. It does not matter if they understand what each unit does, but how they work together during emergency situation is crucial. Combining these units for teamwork training and simulation activities can improve teamwork and communication during patient emergencies, which can then lead to better maternal and fetal outcomes.
Teamwork is an important aspect in any field of work one may pursue throughout a lifetime. A breakdown in teamwork in a business setting can lead to deadlines being missed, which may or may not have an impact on the business, whereas a breakdown in teamwork in a healthcare setting can lead to negative patient outcomes. The correlation between teamwork and patient care outcomes is teamwork is supposed to improve the quality of patient care, and adverse events happen when a patients’ health care team is not acting as one (Ehrenberg et al.,2016).
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Teamwork is defined as “various disciplines working together to address the needs of patients” (IOM, 2003, p 54). Communication and collaboration within the group setting are important characteristics for efficient teamwork. These various disciplines offer a wide variety of skills, knowledge, and methods that may be essential collaborating to make a plan of care. Collaboration means that all members involved with a patients care are listened to and decisions are made together as a team (Finkelman, 2019). Working in a hospital setting, members of a team range between nurses to physical therapists. On a maternity unit, team members are more specific and usually include nurses, midwives, obstetricians (residents and attending), and anesthesiologist (Phipps et al., 2012). In some cases, based on a patents medical history, other members may become involved in care, but for the most part theses are the main team members. Inadequate teamwork during emergency situations can have detrimental effects on both mother and fetus (Cornthwaite et al., 2015). Teamwork training is a way to improve patient outcomes and make for a better birth experience for women and their families (Phipps et al., 2012).
Context
Working in a hospital that is a Regional Perinatal Center in upstate New York might seem like a scary place to work for some, but for others it is a very rewarding place to work. The Kienzle Family Maternity Center at Crouse Hospital is an 80-bed maternity ward that is split between 2 units. Labor and delivery (L&D) is one unit, and postpartum recovery is a separate unit, both units care for high-risk antepartum patients. One would assume that L&D and the postpartum floor is one unit, but as an employee on L&D for the past 4 years, they are anything but one unit. The lack of teamwork and collaboration between the two units, at times, has affected the safety of patients.
One thing all of our patients have in common is that they are all pregnant. The medical complications, which require them to be hospitalized, range from maternal to fetal complications, antepartum and postpartum, although the majority of our patients are full term and admitted to deliver their baby. Unstable patients stay on the L&D unit where residents and physicians can monitor them closely. This includes, but is not limited too, patients that have been diagnose with preeclampsia that are on a magnesium drip, patients bleeding due to an abruption or placenta previa, or a patient that has come in with preterm premature rupture of membranes (PPROM). Stable patients can be transported to the postpartum unit. This includes, but not limited too, antepartum PPROM patients or postpartum patients.
The core competency of teamwork and collaboration comes into play when medical emergencies happen. On L&D these emergency situations are more common that on the postpartum/antepartum unit. Cord prolapse, shoulder dystocia, abruption, seizures, to name a few, are the unstable patients that stay on L&D for close monitoring. Postpartum hemorrhage and precipitous preterm deliveries are events that can happen on the postpartum unit that some nurses are not ready for. Some nurses are more equip to handling theses emergencies based on having experienced them before, but others have no idea what they are doing. I only say this because in the event of these emergencies, the resident and attending usually call for L&D nurses to assist them. Teamwork between the two units is a struggle when the postpartum unit staff doesn’t completely understand everything that we do on L&D and vise versa. Expanding on that, we are not a perfect team on L&D either. Unfortunately there is a high turnover rate of nurses on our unit, so there are constantly new nurses on the floor that are unfamiliar. We have recently seen new physicians on the unit that have come from different hospitals and have different ways to practice that are unfamiliar. Upstate Hospital residency program works on our L&D floor because of the perinatal center, so every July 1st there is a new group of residents that join our team who are unfamiliar. The word ‘unfamiliar’ keeps coming up and it has a purpose. A team cannot work together if they do not know each other. There are many strategies to help enhance teamwork between nurses, physicians, and units, to improve patient care outcomes whenever and wherever emergencies may happen.
Improving patient outcomes
Strategies
“Those that work together should train together” (Cornthwaite et al., 2015, p 1045). This is not just going through the motions of what to do in specific patient emergencies, because no one emergency is the same. Every patient’s health history is different and that will affect the course of action taken in the given situation. As stated earlier, communication between team members is a key to efficient teamwork. A team cannot function without communication, but how one communicates is what really makes a difference. A program called TeamSTEPPS is an evidence based teamwork system that focuses on communication and teamwork skills as a way to improve patient care outcomes (Finkelman, 2019). This training program is for all healthcare professionals to integrate teamwork principles in any healthcare setting. There are four individual teamwork skills one can gain from TeamSTEPPS training; (1) communication-how to effectively communicate accurate information to members of the team; (2) leadership-ability to maximize team actions and resources, (3) situational monitoring- assess situation and maintain awareness; and (4) mutual support- anticipate and support team members needs (Finkelman, 2019). Research shows if individuals can acquire these basic fundamental skills, it can enhance teamwork outcomes in performance, knowledge, and attitude. (Finkelman, 2019).
A program like TeamSTEPPS is the foundation for efficient teamwork in the healthcare setting. The next step would be to take these newly acquired skills and put them to the test. The use of simulation training is growing in the obstetric world and while TeamSTEPPS focused on developing comprehensive teamwork skills, simulation training focuses on developing skills (Phipps et al., 2012). Simulations recreate clinical scenarios that are considered important to understand, and it is also a safe and controlled environment to learn new skills (Argani et al., 2011). Although simulation training appears to be completely hands-on learning, strong simulation programs include didactic and debriefing sessions (Argani et al., 2011). The didactic portion of the training ensures that all participants have basic knowledge of the situation. The simulation is the hands-on experience. This allows members to practice and make mistakes without the fear of harming a real patient. Simulations not only focus on practical skills, but can also enhance communication and are great team-building exercises (Argani et al., 2011). Debriefing after the simulation allows for all members to reflect back on the situation, discuss the thought processes of those involved and actions taken, and how to improve future performances to enhance patient outcomes (Finkelman, 2019).
Barriers
As beneficial as theses two programs would be to any institution to improve teamwork and collaboration between health care providers, there are some barriers that prevent the implementation of these programs. TeamSTEPPS training program is very time intensive. The training manual is a 4-inch binder filled with paper, DVD’s and handouts (Thomas, 2012). It can take up to two days to complete all of the training. Two days does not seem like a long time, but when you want all employees from both units involved in the training, it is going to take a lot of planning to assure everyone is included. Scheduling would be important because nurse managers would have to accommodate for all shifts. For example, a night shit nurse would not be able to work on the unit for 3-4 days. They cannot be scheduled the night before training starts or the nights coming off of a training day, and doctors would be in the same situation with coverage. This can lead to staff shortages on the unit, which can be unsafe for patients. This would also be a huge financial cost to the facility (Thomas, 2012). You would be paying for the training sessions that would be taught numerous times because there is no way that one of the largest maternity centers in Central New York can shut down for two days so staff can attend teamwork training. Another barrier is TeamSTEPPS is not organization specific, which is important for team training programs (Thomas, 2012). TeamSTEPPS is just the foundation and to build off of and other strategies need to be implemented. This is where simulation comes in, which can also be very expensive and time consuming. The institution needs to develop a program specific to the needs of the trainees and then invest in the simulation equipment that best meets those needs (Argani et al., 2011). Time needs to be taken to properly create these simulations because “poorly constructed and executed simulations can reinforce bad habits”(Argani et al., 2011, p 1), which is the opposite of what you want.
Implementation
Money is an unfortunate barrier that can prevent the implementation of these teamwork-training methods, but programs like TeamSTEPPS are very important. Communication is key in teamwork and these programs really emphasize on that. As stated above, a hospital cannot be shut down for training like this, but with adequate planning and scheduling, it can be done. An institution may seem like spending money on this training is out of reach, but it will pay off in the long run. Similar with simulations, they can be expensive, but what institutions are really investing in are improved patient outcome and a decrease in adverse events. Simulation programs can be beneficial in more ways than just a training method. They can serve as refresher courses and can help health care facilities stay up to date by introducing new technical advances. (Argani et al., 2011). A way to save costs would be to have new staff go through the didactic and simulation training during the orientation period, while seasoned staff participates is a course that has a shorter training time (Phipps et al., 2012). Some teamwork training is better then no training at all, so if money is the reason why theses programs cannot be implemented, looking into less expensive course should be a priority.
Discussion
Teamwork training program should really be a hospital wide course mandatory for all staff. For two units in the maternity center, there should be an emphasis on teamwork, collaboration, and communication. Twice a year, there are mandatory drills that involve nurses, doctors, assistants and unit secretaries. These drills are mini-simulations in which we are given a scenario, run the drill, and then debrief. We have nurse educators and a clinical nurse specialist that have a background in L&D and work specifically with the two units. I can work with them to make a plan to repeat drill scenarios that are most common. On L&D we can focus on shoulder dystocia, eclampsia, and breech deliveries. These events are more likely to happen on L&D but very rarely would a postpartum nurse encounter situations like these. Simulation drills that involve both units would include emergent situations like postpartum hemorrhage or precipitous deliveries. These are scenarios when L&D nurses go to the postpartum unit for assistance. If we all practice together in drills, we will all know how to work together in an emergency. Along with drills, we also have mandatory skills classes twice a year as well. The past few skills classes focused mostly on reading fetal strips and placing fetal scalp electrode, which we as nurses do not even do because we have resident physicians that place them. I could work with the educators to incorporate teamwork exercises into one of the upcoming skills classes.
There are some challenges to trying to incorporate these ideas into drills and skills classes. These educators plan weeks and months ahead of time to assure that the information presented is accurate, meets our educational needs, and that they run efficiently. Even if I bring up these ideas to them tomorrow, they may not be incorporated into these classes for months or even a year. The educators are the ones who are researching best practice scenarios to keep us all up to date and there are greater educational needs than teamwork exercises. If incorporating teamwork exercises into skills class is unlikely, then advocating to create a class focused on teambuilding should be created. It can be once a year and each year can serve as a refresher course. Quick and easy but can reinforce the importance of good teamwork between the two units.
Conclusion
Medical emergencies can happen anywhere at anytime, and staff needs to be properly trained to handle these situations. Training includes not only improving skill set, but proper communication and teamwork as well. Patient outcomes are enhanced when all members of the healthcare team work together. Training programs, like TeamSTEPPS, educates staff on how to adequately work as a team, but this training alone does not improve teamwork. Simulations are a way to practice skills, practical and teamwork, before engaging in a real-life emergency. These two strategies together will enhance patient outcomes. Implementing teamwork-training classes and simulation training into educational requirements can help eliminate the assumption that these two units act as once, because with this combined training, these two units can actually work together as one and provide for safer and more enjoyable birth experience for mother and baby.
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