alt The patient was having an MI, complicated by intermittent runs of ventricular tachycardia. Despite his serious condition, the good-natured patient, sensing the unspoken anxiety of the emergency physician, masked his fear by gently joking with the providers. As the nursing staff began initiating the ACS protocol, the EP stepped out of the room to call the cardiologist to activate the cath team. He returned only a few minutes later to find the resident and the nurses arguing in front of the now worried patient.
The resident’s demand for the nurses to prepare medications for cardioversion had been refused. Some nurses vocalized the need for emergent intubation while the physicians responded that it was not necessary. The patient continued to lay quietly, in the middle of this verbal exchange, his condition steadily deteriorating…

What happened in the course of a few minutes that resulted in tension and chaos? Could the EP have contributed in some way to the team conflict? How could the EP prevent this type of situation from occurring?

As an experienced emergency physician and medical director, I appreciate all too well how easy it can for a situation to get out of control and for a leader to lose control. The ED is high stress and fast paced, every provider coming from a different background. And that’s on a good shift. Other factors that make the ED a chaotic mess waiting to implode: Team members work independently as well as interdependently; providers often have strong, direct personalities; EPs are responsible for implementing multiple competing directives at the same time (like decreasing length of stay while improving quality of care).
We all know that we can’t succeed in this environment without teamwork. And yet, ironically, with as much education as EPs receive, we often lack the real-life training needed to lead and manage a team of individuals. We must realize that our medical liability is tied to every team member with whom we work. And we are only as strong as our weakest link. Therefore, it is paramount that the emergency physician practice leadership skills that bring the different team members together to a common goal.

Leadership is really about three things: giving direction, implementing plans, and motivating people. And these functions can be accomplished using different styles. The U.S. Army Handbook describes three leadership styles: authoritarian or autocratic, participative or democratic, and delegative or free reign. Good leaders usually have one dominate style but adapt their style as needed and effectively use all three. Ineffective leaders are limited to their dominate style and are unable to adapt to a situation or the person with whom they are interacting. It is important for the leader to lead in a manner that is best received by each individual team member.

Authoritarian: Traditionally, physicians have used an authoritarian style of leadership. Doctors evaluate patients and write nursing orders. In this model, the leader (doctor) tells employees (nurses) what to do without soliciting or incorporating advice from employees. The limitation of this model is that it does not allow for two-way communication that may be needed to mitigate errors. The Joint Commission as well as other regulatory agencies require organizations to develop team cultures that foster exchange of questions for the safety of the patient. Physicians are fallible and need the checks and balances through communication to prevent errors. Used too frequently, the authoritarian style can affect nurse motivation and morale. However, there are situations appropriate for the authoritarian style. A critical situation, such as a cardiac resuscitation, clearly requires one leader to give direction. To function effectively, a code team must work together like an orchestra that has only one conductor. However, the team members still have the obligation to speak up if an obvious error is being made.

Participative: Participative leadership includes one or more team members in the decision-making process while the leader maintains the final decision making authority. Asking a nurse for their input is a way to exercise this type of leadership. With such a leadership style, it is important for leaders to hire team members who are competent and comfortable taking initiative. Good leaders help their team members to grow their knowledge and skills to utilize them in the best manner.

Delegative: In the delegative style, the leader allows the employees to make decisions while maintaining responsibility for the decisions that are made. Think about the ED that has order sets that nurses can implement based on their own unsupervised nursing assessment. Nurses are making decisions for which the doctor is responsible. Such physician leaders empower the nurses to think critically and implement plans without direct supervision. This can promote confidence and improve efficiency and morale. But when an error is made, the leader does not punish and blame but instead uses the incident as a teaching opportunity. They also recognize the contributions of the team members and praise often.

The basis of most ED errors is rooted in poor communication. As such, the Joint Commission has identified improving communication effectiveness among caregivers to be one of its highest goals for 2007. One strategy to improve the effectiveness of communication, after evaluating a patient, is to take a minute to share your plan of care with the other team members. This allows both physician and nursing staff to work towards a common goal. Then if the plan is not going as expected, everyone will be alerted to alter the plan.

Some of my least favorite words to hear from a nurse are “just so you know.” This is often followed with documentation in the chart of “MD aware.” These words often signal a broken interaction and only function to shift the blame for a bad outcome. It calls for action on both sides to pause and make time to engage in effective communication. The nurse has a need to communicate a concern which the physician should not dismiss but acknowledge and address. The physician can also take this opportunity to explain his thinking, answer questions and allay any concerns. On the one hand, failure to report a bad patient response to physician because he is “unapproachable” can result in a malpractice claim for a delay in care. Conversely, the failure to report positive patient outcomes may delay disposition of the patient and jam the ED with waiting patients.

In The Leadership Moment, author Michael Useem describes the case of Wagner Dodge, a famous firefighter who was assigned a new team of firefighters to put out a fire in Mann Gulch, Montana in August 1949. Although well known by reputation, when he took 16 men from an airplane into this fire, he made several critical mistakes that very quickly cost him the respect from his team. Then, just as the fire was about to overtake them, Dodge lit another fire, jumped into a circle of flames and then beckoned for the team to join him. But the team didn’t know their leader, didn’t know they could trust him and follow even when his actions made no sense. They ignored his signals, and in the end, Dodge was one of only three to survive. He asked his team to follow him but failed to communicate why.

How does this story apply in the ED? In today’s world of nursing shortages and high agency nurse utilization, it is certain that you will, from time to time, work in an ED with a staff who does not know you well. As a leader, you must find a way to engender trust with the people you lead. The only way to accomplish this is to communicate. Take time to get to know your team members and disclose information about yourself. Communicate your vision and expectations. Initiating a dialogue prior to a crisis situation will undoubtedly help the team trust your thinking and decision making. Consider how many times you ask for two functioning peripheral IVs before you intubate someone. My nurses sometimes think I am being overly cautious. But having intubated enough people who lose an IV somewhere in the process makes me expect the unexpected. So when I explain my experiences and concern to the nurses, they understand my rationale for the request and are more likely to help me.

A corollary to communication is the importance of the people with whom you communicate. Be an active partner to the charge nurse. That person is second only to the EP in their responsibility to move patients efficiently. If you ask a charge nurse and an EP what they want most in the other, they will answer simultaneously: Someone who can move patients. So it is imperative that these two people communicate. If four patients need to be reevaluated and given a disposition in order to create more beds for the high acuity patients being brought by ambulance, both charge nurse and EP must share the same sense of urgency and assist one another to help maintain flow. Good communication with the charge nurse is critical to keep the ED flowing smoothly.

Emergency physicians have a tough job and it only gets tougher if we try to go it alone. We must step up to the plate and assume our roles as leaders, recognizing the need for good communication in order to develop our teams. Recognize the value of every ED team member. We need to role-model effective teamwork behaviors by practicing and promoting effective communication. Include team members in planning and problem-solving. Help one another and recognize the contribution of each member. These things seem simple, and they can be, but they all take time. And time is something we have precious little of in the ED. It is time well spent, however. Spend a few minutes each shift building an effective team. And when the time comes they will follow you into the ring of fire.
See next page for take-away notes
{mospagebreak title=The Take-Away} 
Adapt to Lead: Take-Away Lessons 
Whether you are a naturally authoritarian leader or one who tends to delegate responsibility, learn to adapt your style to the situation at hand. A good leader must read a situation and lead in a manner that best suits those around them.
Teaching Point:
If you delegate responsibility and empower nurses, be prepared to respond: praise when things go well, and teach when there is an error.
After evaluating a patient, take a minute to share your plan of care with the other team members. This fosters better communication and allows both physician and nursing staff to work towards a common goal.

Your personal experiences often guide you patient interactions, making you more or less cautious in handling certain scenarios. Explain these rationales to your staff so that they understand, and are on board with your plan of action.
Talk & Move:
One essential key to moving patients efficiently is to communicate effectively with your charge nurse. You are on the same team, so communicate accordingly.
Take Time:
Building a positive team environment takes time. Carve out a few precious minutes each shift and dedicate them to improving the team atmosphere in your department. 
Michael Silverman, MD, is the ED Director at Harbor Hospital in Baltimore.


# Leadership MomentJohn Dallara 2007-07-29 18:13
Nice commentary on a critical subject for all EPs. I can't remember the number of times things have gone awry because the doctors and nurses failed to work together to solve a problem with a critical patient. A big part of this is whether the EP has an effective leadership style and a history of being a good leader with those nurses.

Also read "the leadership moment" on your recommendation. A bit tough in a few places -- such as the material on TIAA-CREF -- but worth it.

John Dallara, MD BCEM
Chapel Hill, NC

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