January 18, 2015

One thing ED nurses wish docs knew

By Daniel Cabrera

Author: Erin K. Salo, R.N.



When I signed up for Emergency Department nursing, I was fairly sure of what I was getting into. I had worked in a small ED in finance before becoming a nurse and thought that was plenty of orientation to the environment. Emergency Rooms, after all, are very unique places with unique dynamics that few outsiders truly understand. After working in Oncology and ICU settings as a nurse in several different states, I was sure I was more prepared than almost anyone for what the ED could throw at me.

After one year in the ED, I found it wasn't the septic patients, the complaints at the triage desk, or the barrage of trauma patients that was too much. It was this overwhelming idea of teamwork.

I want to do things my way. I wanted credit for converting that patient's fast heart rate with vagal maneuvers or that awesome IV start. Gone were the days of my timed lists of when to give medications, do a dressing change, or roll a patient to their other side. I was called to be "flexible"; which is a socially acceptable way of saying "check your agenda at the door and do what will serve the greater good of the team and the patients". Suddenly I had to depend on my team to help me efficiently and safely take care of the steady stream of patients at the door instead of depending on largely myself. It was a hard pill to swallow. I'm still learning.

I realized quickly that I can be an excellent nurse if I want to - because that choice depends on me. I can choose to read current research, I can master difficult IV starts, I can practice time-management skills, I can be patient and diligently manage difficult IV drips. I can be great at these things because it only takes me to accomplish them. I control me. Those are some of the skills that make a great ICU nurse.

Little did I know that it would take all those clinical skills AND being a good team member to be a great ED nurse. I can't control the team like I can myself. This is not a place for any team member to be a maverick or "take your ball and go home" if you don't get your way. It is not a place to hold a grudge. It is not a place to disrespect or belittle other members of your team. If we do, the team suffers. Ultimately, the patient suffers.

Patients suffer when we - nurses, physicians, PCAs, etc. - don't communicate effectively and respectfully with each other. They suffer when we place more importance on ourselves and what we want (a one hour lunch break exactly at noon? Taking any patient except that difficult psychotic one?) than on what is best for the team, the patient, and the patients waiting to be seen. They suffer when we don't communicate well. Great plans are nothing if not communicated. If the plan of care isn't communicated effectively, it can't be executed well. If progress isn't reported back in a timely manner, patient care suffers as well.

If this wasn't complicated enough, every day we work with different team members. Rarely are two days alike. We need to figure out how to be a great team every day with a new set of people; different personalities with different preferences. All while still managing great, efficient, evidence based patient care. Whew!

If there was one thing I would say to a new ED physician or resident it would be this: academic achievements are only half of the equation of being a great physician. The other half is learning to function as a team member and leader. The same is true for nursing.

The Emergency Department works best as a team and you, the physician, are or will be the leader of it. We know you have what it takes. You aren't an impostor; although you may feel like one at times. We know you can be a good doctor if left on an island by yourself. We know you can do this because you have dedicated a large portion of your personal time to studying, test scores, interviews - and you've succeeded. You are disciplined.

Never before has so much information been readily available at your fingertips. Resources are a phone call away. However, while you are still working on obtaining knowledge and experience, hopefully you are also are learning how to be a good team member and how to be an effective leader. That is not something you can look up Google. Being a strong leader is equally important as the academic knowledge. There are times when finding the right answer isn't as hard as working with the team to execute the delivery of the right answer.

You can have all the right answers but still be a mediocre doctor if you aren't a good team member.

As the leader of this team, nurses need physicians to tell us what you are thinking. The team wants to hear your rationales. What are you looking for with that CT scan? What happens when it is positive? Negative? Why aren't you prescribing antibiotics? If you tell us, we can communicate that to the patient when they ask us on their way out the door and save you another trip into their room. When we know the plan, nurses can anticipate needs and make decisions without burdening you with every small detail.

If you want to be a great physician, listen to your team. Let them be an extra set of eyes and ears for you. They might have a silly concern you can easily dispel with science, but they might also have an instinctual insight worth investigating. At the risk of sounding mystical, gut feelings happen and are worth investigating. Perhaps their past experience has something to offer in this new situation.

Being a good leader includes remaining approachable. If you have created an environment where the team you are depending on does not feel like they can approach you with problems, concerns, or mishaps then perhaps you aren't an effective leader.  There will be glitches in the plan of care. Events will not always go our way. Mistakes will happen. Part of being a great leader is taking the glitches and mishaps in stride and going with the second best plan. Hopefully without belittling a fellow team member in the process.

There are times when being a great leader means just that: lead! Take charge of that chaotic situation, be the one voice the team will to listen to. This takes experience, certainly; a skill to be developed. However, while you are strongly being that traditional leader, you can still be respectful. You can still teach. You can still inspire the team to follow you. A truly great team develops when there is mutual trust and respect.

The wonderful thing about the ED is that we are in this together. A patient may come under your care that would overwhelm you and paralyze if you were alone. If you want to be a great physician, talk to your team. Listen to your team. It’s hard to be great on your own.

The best days in the ED have not been when the smartest physician with the highest MCAT score is on. The best days are when we have good team dynamics, mutual respect, and everyone striving for the same goal: safe, evidence based, patient centered care.

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Excellent article, Erin!!!


I agree on the skill set, thank you for putting your reflections into words.

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