- Email: [email protected]
High performance team interaction in an air medical program
ORIGINAL RESEARCH
High Performance Team Interaction in an Air Medical Program Sherry A. Stohler, RN, MSN’
Abstract 1.
UFE STAR, Corm.
Hartford
Hospital,
Hartford,
introduction:
The purpose to identify
study
was
and
describe
ments
of a high performance
team
Address for correspondence and reprints: Sherry A. Stohler, RN, MSN, LIFE STAR, Hartford Hospital, 80 Seymour St., P.O. Box 5037, Hartford, CT 06102-5037
Methods:
The
described
by Giorgi
Key Words: teams
around
air medical,
high performance,
on an air medical
collection
0 1998 by the Air Medical
United
jective
no. 7411192487
+ 0
Results:
method
used
as
to guide
data
Sii flight nurses
from
States
were
interviewed
described
their sub-
of a high performance
Four themes
collaboration, standards,
team
mutual
emerged respect
Conclusion:
Implications
volved
high performance
may
from
the data:
and trust,
Mness
and synergy. in this
require
lo promote
116
the eleinteraction
mission.
was
as they
perception
qualitative
experience.
1067-991W98/$5.00 Reprint
Journal
transport
phenomenologic
and analysis. the
and audiotaped Copyright Associates
of this
attention
for flight
to the identiiied
team performance.
crews
in-
environment themes
Introduction The personnel involved in an air medical transport service must work effectively as a team to accomplish the response, rescue, and resuscitation of the critical patient while en route to a tertiary care facility. A high level of team interdependence is necessary to overcome the obstacles common to rescue missions or critical care transport and allow the team to provide optimal patient care in an unpredictable environment. Air medical programs generally employ highly skilled and credentialed individuals who possess technical competence, hardiness, commitment, and highly developed skills in clinical decision making and critical thinking.’ These characteristics are essential for the high performance team environment. Team members also share these attributes: a commitment to a common purpose, a shared experience of empowerment, a high level of communication, and a high degree of flexibility. They also experience a significant level of recognition, appreciation, and morale.2 Flight nurses are an essential compe nent of the air medical transport program: 91% of all flight programs have at least one flight nurse on board for patient transporL3 In most U.S. flight programs, the nurse functions as the patient care team leader and manages the critical, unstable patient before and during transport. This responsibility requires a mature clinical practitioner with a high level of autonomy, as well as a willingness to depend on other team members.
July-September
1998 17:3 Air Medical Journal
In his book The West Poilzt I%‘~JJ of scribe this phenomenon relevant to their Leadership, Donnithome” describes the practice. process of developing leaders at this renowned military academy. Individual Methods high performance standards are outlined Phenomenology attempts to describe within a team concept. Donmthome de human experience as it is lived.7,sThe scribes successful problem-solving situa phenomenologic method described by tions that allow individuals to function ef- Giorgi was used to guide data collection fectively under the stress of war and and analysis. Data are collected through within the high performance team struc- in-depth interviews using an inductive, ture. The qualities of courage, determina- descriptive approach. In this study, the tion, integrity, and self-discipline are phenomenologic method was used to fa taught at West Point with the goal of de cilitate an understanding of the “lived exveloping good leaders and good follow- perience” of the flight nurse who deers, both of which are essential ingredi- scribed a high performance team ents of a high performance team. interaction. The research question was: Bohan” also describes the essence of what are the factors that contribute to a building a high performance team. The high performance team situation? high performance organization exceeds customer expectations, which requires a Definition of terms A flight nurse refers to a registered total commitment to quality and productivity. Therefore hiih performance orga- nurse who has completed a curriculum nizations are excellent and competitive. of study specific to the practice of flight Building a high performance team is de nursing. A flight nurse’s primary clinical scribed within the context of creating a responsibilities are to provide care to critvision to guide that performance. The ically ill or injured patients during air team’s involvement in creating this vi- medical transport sion is essential to the hiih performance High performance team refers to a concept. group that shares a collective vision and VailP describes “high performing sys conducts an intense mission. The high terns” (HPSs) as human systems that performance nature of their work is eviperform at levels of excellence far be- denced by all the components and funcyond those of comparable systems. He tions of the mission coming together to describes the characteristics of HP% as facilitate optimal patient care and team an elevated level of commitment and mo interaction. A situation is a clinical encounter withtivation, teamwork focused on the task, strong and clear leadership, and a strong in a high performance team framework consciousnessthat “we are different.” Although Donnithorne’ and VailP Participants A convenience sample of six staff share their experiences and observations of HPSs, their descriptions of high per- flight nurses employed in U.S. air medformance team interactions that support ical transport systems was selected. the listed characteristics are lacking. In Sample size is consistent with the chosen the articles that refer to the terms high phenomenologic method. Three participerformance teams and high pe7forming pants were men, and three were women. systems,few authors reported research Age of the participants ranged from 30 to on these topics; instead they gave anec- 45 years with a mean age of 38. Number dotal or theoretical information. This gap of years employed in nursing ranged in information provides an opportunity to from 9 to 20 with a mean of 13. Years of contribute to the literature by describing, flight nursing experience ranged from 5 through data, the elements of a high per- to 15 years with a mean of 7.5 years. Primary states in which participants pracformance team encounter. The purpose of this study was to de ticed flight nursing were California, scribe the flight nurses’ perception of the Washington, Vermont, New Hampshire, elements of a high performance team sit- Massachusetts, and Connecticut. Potential participants were identified uation. The qualitative approach provides an opportunity for flight nurses to de- through contact with air medical proAir Medical
Journal
17:3
July-September
1998
Phenomenologic Method Concepts Bracketing The process of identifying and suspending any preconceived notions regarding the phenomenon under investigation Saturation The sense of closure experienced by the researcher when data collection ceases to provide any new information Triangulation The use of multiple methods to collect and interpret data about the phenomenon being studied to arrive at an accurate representation of reality Polit D, Hungler 6. Nursing research: principles and methods. 5th ed. Philadelphia: Lippincott; 1995.
gram managers who gave the names of flight nurses planning to attend the 1996 Air Medical Transport Conference in Fort Worth, Texas. Potential participants were given a telephone presentation of the research project to ensure voluntary participation and verity participants met study inclusion criteria, which consisted of being a registered nurse currently working in the field of flight nursing and employed as a flight nurse for at least 2 years. At the conference, before data co& lection, the purpose of the study was explained to each participant, and informed written consent was obtained. The crew contigurations represented in this study included nurse/nurse, nurse/paramedic, and nurse/respiratory therapist. A crew configuration not repro sented in this sample was nurse/physician, a fact that may be regarded as a limitation of this study. Data Collection Data were gathered by in-depth interviews conducted by the principle investigator. The investigator used bracketing to identify and suspend any preconceived notions regarding the phenomenon under investigation.7 All interviews were tape-recorded. The participants were asked three open-ended questions to elicit information about their experience with a high performance team situation on an air medical transport mission. An 117
interview guide was used to ensure consistency among interviews. The questions were: l Why did you become a tlight nurse? l Describe an experience of a high performance team interaction on an air medical transport mission. l Describe a situation that did not re fleet a hiih performance team interaction on an air medical transport mission. Additional questions were asked to provide clarification and to encourage participants to fully describe the meaning of their experience. The number of participants interviewed continued until saturation was achieved, and data became redundant. Saturation describes the sense of closure experienced by the researcher when data collection ceases to provide any new information.7 When necessary, participants were contacted after the interview so certain descriptions could be claritied. Triangulation, the use of multiple methods to collect and interpret data about the phenomenon being studied to arrive at an accurate representation of re ality,’ was chosen as a method of validating the information obtained in the interviews. The principle investigator observed an air medical transport with two participants. These observations pro vided an opportunity to determine the accuracy of the described phenomenon of the high performance team interaction. A transcript of each interview was made and then analyzed using the phenomenologic method described by Giorgi.8This method involves five steps: 1. After interviews are recorded and transcribed verbatim, data are read in their entirety. 2. Data are reread to identify units in the experience called constituents. 3. Redundant constituents are eliminated, and units are related to each other. 4. Concrete language is transformed into abstract concepts. 5. Insights are structured into meanings of an experience. All data were reviewed for congruency by a researcher experienced in the phenomenologic method. All coded tapes and written transcripts were destroyed after data analysiswas completed. 118
Results Participants described their reasons for becoming a flight nurse. These reasons included role models and experience, an attractive image, opportunity for teamwork and affiliation, autonomy in clinical practice, and the opportunity to make a difference. Most participants were attracted to flight nursing because of exposure to a flight nurse while working in a ground ambulance, the military, or the community. The participants described an image of highly developed communication skills, strong decision-making abilities, professional attitude, and impressive performance. The combination of flying and performing at an advanced practice level with a variety of patients was viewed as an attractive career choice. Working as a team member and team interdependence were identified as positive characteristics of this nursing specialty. The participants identified the flight nurse, paramedic, respiratory therapist, and pilot as the core team members. Other team members were fire department and EMS personnel at the scene and nurses and physicians at referring facilities. Four themes were identified as representative of a high performance team interaction: collaboration, mutual respect and trust, maintenance of fitness standards, and synergy. Each theme will be described in detail. Collaboration. Each flight nurse in the study described collaboration as an essential component of a successfulhiih performance team interaction. Participants reported that team members collectively performed patient assessment, conducted procedures, and developed a back-up plan. Other factors included team members showing respect for others providing care to patients and having a good working relationship. One participant said, “We had a scene flight for a motor vehicle crash victim. An emergency medicine resident was on board as a third crew member. No extrication was involved, so we didn’t have much time to prepare. We made our assessment together, and it was all very quiet and controlled. We decided ahead of time who was going to be the team leader and who was going to manage the intubation, and every person functioned at a high level.”
All participants described a lack of collaboration when discussing a situation that did not represent a high performance team situation. The flight nurses said the team in these situations did not discuss the plan for patient care, stumbled over one another while doing the same things, performed redundant acts that lacked team coordination, and lacked agreement as to who should intubate. Independent actions not involving the team process consistently were mentioned, as well as a lack of coordinated effort. One participant related this story. ‘We were going to a scene call for the victim of a gunshot wound to the head. My partner and I had some complications going in. We got trapped by weather, and we didn’t find the scene right away, so my partner and I were already at a level of frustration before we got on the ground. We were stumbling over each other, trying to back up and get some of the patient report. The patient had become more unstable, and the aircraft we were in was a back-up aircraft that we were not used to working in. The patient was bleeding all over the place, the cuff on the ET tube was tom, and we needed to reintubate him in the aircraft. I thought I should be doing the intubation, and my partner thought he should do it.” Mutual respect and trust. All participants listed mutual respect and trust as part of the high performance team situation. They mentioned confidence in their partner, clinical competence, and knowing one’s practice limitations. Hiih experience and skill levels and the ability to perform quickly and efficiently also were described as ingredients essential to developing respect and trust among team members. One study nurse said, ‘We were dispatched to a serious motor vehicle crash-rollover with ejection of the occupant. The paramedic had immobilized the patient, started intravenous lines, just gotten the patient intubated, and reported that the patient had a tension pneumothorax. We were able to treat the pneumothorax in the helicopter. Both crew members maintain the same level of competency, so that if I were to stop a procedure at some point, my partner could take over for me.”
July-September1998
17:3
Air Medical Journal
Another relayed, ‘We were called to tance of flight crew members meeting the scene of a van rollover with five adult physical fitness standards was menvictims. Two of the patients were unre- tioned because they allowed the team to sponsive and were a distance from one accomplish a flight rescue mission in another. We asked the EMTs to bring which a patient was trapped on the side the patients closer so we could work on of a mountain. In this case, crew memthem simultaneously. Both patients re- bers had to use their physical strength quired intubation. I left my partner with and endurance to hike significant disone of the patients while I loaded the tances while carrying rescue and medother on the helicopter. I felt very conti- ical equipment dent that when he brought the second Additional skills required of team patient to the aircraft, all would be status members were high and low angle rescue quo with the tube position, and every- techniques, both of which mandate a thing would be fine.” great deal of physical fitness. A situation Some participants described a lack of that did not represent a high performance mutual respect and trust in a situation team interaction resulted from inconsis that did not represent a high perfortency in the team members’ commitment mance team interaction. Specific situa- to meeting physical requirements. tions they described included a partner’s Synetgy. Each flight nurse described lack of clinical competence and unful- synergy as the result of a successful high filled expectations of the partner’s perfor- performance team interaction. One elemance. A participant said, “I made an as- ment of synergy included effective comsumption that my partner knew what he munication with team members, which was doing. Had the call happened with developed after working with a partner another partner, it would have gone over time. Communication that did not more smoothly. I was frustrated to think require speaking or only a few words I had to tell him everything to do to keep also was described; in such situations, a the endotracheal tube from coming out.” look was all the communication necesOther descriptions included not giv- sary to orchestrate patient care. ing crew members credit for what they One nurse recalled, “We initiated a knew and sensing that one member did system of monitoring both patients durnot value the other as a team member. ing transport without even speaking. We One nurse said, “We were on a rotary worked for so long together that we flight. I was a fairly new nurse with this knew what the other person was going to flight program, and I was working with do. The care rendered was totally optisomeone I didn’t work with a lot. We mal, and we didn’t compromise in any sitwere going for a really sick diabetic ke- uation; even the pilot had to give report. toacidosis patient who already was hav- Every one of us was doing a job and ing seizures and not doing very well. The knew what we had to do and how we had moment the call came, my partner and I to do it.” Another participant said, ‘mere was were not communicating very well, and things were very disjointed. She had a good communication between us and the lack of confidence in me, and I didn’t prehospital care providers, and there was know her very well. I think that made a lot happening in the helicopter on the things a lot worse. way back. Fortunately, I was working “I was taking report, and she would with a team member I worked with a lot. keep interrupting and asking questions There were several procedures that had that I already had asked. We got back to be done within a l@minute period, and into the aircraft with the patient, and I we got through all those procedures with would do something, and she would to- very little communication. It’s always tally do the opposite. It was just a very good to know that when you finish, you difficult flight because I was angry that know the communication was just about she didn’t trust me to take care of the as good as it could get between you and patient.” your partner.” Fitness standards. Another theme ‘We were on a tixed-wing interfacility identified from the interviews was fitness flight for a trauma patient,” someone else standards. In one situation, the impor- related. ‘When we arrived at the hospital, Air Medical Journal
17:3
July-September
1998
we knew we had to intubate the patient. The fact that I and my partner worked so well together, we both kind of looked at each other, and we knew what we needed to do. We both immediately set into action without really having to make a lot of discussion because we had practiced it so much together. We looked at each other, and he immediately got set up to intubate.” Some participants mentioned the role of the pilot. Synergy occurred when the pilot optimized the landing zone to afford the flight crew better access to the patient and a safer landing area, gave report for the medical team, and provided reassurance when he sensed the flight team’s apprehension in dealing with a patient on a long transport A participant said, “We were transporting a high-risk OB patient in preterm labor. We were having a lot of diiculty controlling contractions. We were working so hard with this patient, and the pilot was listening to what we were saying, and he was interjecting his own personal experience, having had a few children of his own, of active labor and how much time you have. He was even doing some of the communications for us to the receiving hospital.” Discussion Weick and Roberts,g who observed and interviewed flight deck personnel on an aircraft carrier for 5 years, describe the collective mind as a theoretical concept that provides a framework for understanding reliable and effective behavior in continuous and critical operating organizations. Continuous and critical op crating organizations, such as air medical programs, require a higher level of interrelating and social skills than efficiencyoriented organizations. The concept of heedful interrelating that Weick and Robert@ discuss coincides with synergy; regardless how visionary or capable one person may be, cooperation with others is imperative to respond to such complex conditions as critical care air medical tEUlSpOIt
Many of the transports the participants described were remarkably similar. Although these flight nurses were not accustomed to referring to themselves as members of a high performance team, 119
they easily understood and described this concept ‘Ihe identified themes were interrelated and led to the ultimate theme associated with a high performance team situation: synergy. Summary This project was designed as a descriptive, theory-generating study to add insight to the developing knowledge base of high performance teams as it re lates to the air medical industry.
Identifying and recognizing the themes associated with a successful hiih performance team should be acknowledged and discussed among tlight team members so that positive patient outcome and work satisfaction can result from the air medical transport experience. Program managers and staff need to be aware of the importance of fostering positive working relationships and buiklii team skills that result in highly developed communication and trust. Attention to
clinical competence and established fitness standards is essential to the process of developing high performance teams. Suggestions for future research include interviewing other crew members who participate in air medical transport to determine the accuracy of the phenomenon described by the flight nurses. Also, identifying and interviewing other high performance teams outside of heath care could be used to validate these findings.
ship. New York: Doubleday; 1993. Bohan G. Building a hiih performance team. Health Care Supervisor 1990;8(4):1521. 6. Vaih P. The purposing of high-performing sys terns. Organizational Dynamics 1982 Autumn: 23-39. 7. Polit D, Hungler B. Nursing research: principles and methods. 5th ed. Philadelphia: Iippincott; 1995.
8.
References 1.
National Plight Nurse Association. Standards for flight nursing practice. 2nd ed. St. Louis: Mosby-Year Book; 1995. 2. Blanchard K, Carew D, Parisi-Carew E. ‘Ihe one minute manager build high-performing teams. New York: Morrow & Co; 1990. 3. Mayfield T, Lindstrom A. Medical crew survey. AirMed 19982(5):21-5. 4. Dotithome L The West Point way of leader-
120
5.
9.
July-September
Giorgi A. Phenomenology and search. Pittsburgh: Duquesne 1985. Weick K, Roberts K. Collective tions: heedful interrelating Administdive science Qmterly
psychologkxl re University Press; mind in organ& on flight decks. 1993;38:35781.
1998 17:3 Air Medical Journal
High Performance Team Interaction in an Air Medical Program Sherry A. Stohler, RN, MSN’
Abstract 1.
UFE STAR, Corm.
Hartford
Hospital,
Hartford,
introduction:
The purpose to identify
study
was
and
describe
ments
of a high performance
team
Address for correspondence and reprints: Sherry A. Stohler, RN, MSN, LIFE STAR, Hartford Hospital, 80 Seymour St., P.O. Box 5037, Hartford, CT 06102-5037
Methods:
The
described
by Giorgi
Key Words: teams
around
air medical,
high performance,
on an air medical
collection
0 1998 by the Air Medical
United
jective
no. 7411192487
+ 0
Results:
method
used
as
to guide
data
Sii flight nurses
from
States
were
interviewed
described
their sub-
of a high performance
Four themes
collaboration, standards,
team
mutual
emerged respect
Conclusion:
Implications
volved
high performance
may
from
the data:
and trust,
Mness
and synergy. in this
require
lo promote
116
the eleinteraction
mission.
was
as they
perception
qualitative
experience.
1067-991W98/$5.00 Reprint
Journal
transport
phenomenologic
and analysis. the
and audiotaped Copyright Associates
of this
attention
for flight
to the identiiied
team performance.
crews
in-
environment themes
Introduction The personnel involved in an air medical transport service must work effectively as a team to accomplish the response, rescue, and resuscitation of the critical patient while en route to a tertiary care facility. A high level of team interdependence is necessary to overcome the obstacles common to rescue missions or critical care transport and allow the team to provide optimal patient care in an unpredictable environment. Air medical programs generally employ highly skilled and credentialed individuals who possess technical competence, hardiness, commitment, and highly developed skills in clinical decision making and critical thinking.’ These characteristics are essential for the high performance team environment. Team members also share these attributes: a commitment to a common purpose, a shared experience of empowerment, a high level of communication, and a high degree of flexibility. They also experience a significant level of recognition, appreciation, and morale.2 Flight nurses are an essential compe nent of the air medical transport program: 91% of all flight programs have at least one flight nurse on board for patient transporL3 In most U.S. flight programs, the nurse functions as the patient care team leader and manages the critical, unstable patient before and during transport. This responsibility requires a mature clinical practitioner with a high level of autonomy, as well as a willingness to depend on other team members.
July-September
1998 17:3 Air Medical Journal
In his book The West Poilzt I%‘~JJ of scribe this phenomenon relevant to their Leadership, Donnithome” describes the practice. process of developing leaders at this renowned military academy. Individual Methods high performance standards are outlined Phenomenology attempts to describe within a team concept. Donmthome de human experience as it is lived.7,sThe scribes successful problem-solving situa phenomenologic method described by tions that allow individuals to function ef- Giorgi was used to guide data collection fectively under the stress of war and and analysis. Data are collected through within the high performance team struc- in-depth interviews using an inductive, ture. The qualities of courage, determina- descriptive approach. In this study, the tion, integrity, and self-discipline are phenomenologic method was used to fa taught at West Point with the goal of de cilitate an understanding of the “lived exveloping good leaders and good follow- perience” of the flight nurse who deers, both of which are essential ingredi- scribed a high performance team ents of a high performance team. interaction. The research question was: Bohan” also describes the essence of what are the factors that contribute to a building a high performance team. The high performance team situation? high performance organization exceeds customer expectations, which requires a Definition of terms A flight nurse refers to a registered total commitment to quality and productivity. Therefore hiih performance orga- nurse who has completed a curriculum nizations are excellent and competitive. of study specific to the practice of flight Building a high performance team is de nursing. A flight nurse’s primary clinical scribed within the context of creating a responsibilities are to provide care to critvision to guide that performance. The ically ill or injured patients during air team’s involvement in creating this vi- medical transport sion is essential to the hiih performance High performance team refers to a concept. group that shares a collective vision and VailP describes “high performing sys conducts an intense mission. The high terns” (HPSs) as human systems that performance nature of their work is eviperform at levels of excellence far be- denced by all the components and funcyond those of comparable systems. He tions of the mission coming together to describes the characteristics of HP% as facilitate optimal patient care and team an elevated level of commitment and mo interaction. A situation is a clinical encounter withtivation, teamwork focused on the task, strong and clear leadership, and a strong in a high performance team framework consciousnessthat “we are different.” Although Donnithorne’ and VailP Participants A convenience sample of six staff share their experiences and observations of HPSs, their descriptions of high per- flight nurses employed in U.S. air medformance team interactions that support ical transport systems was selected. the listed characteristics are lacking. In Sample size is consistent with the chosen the articles that refer to the terms high phenomenologic method. Three participerformance teams and high pe7forming pants were men, and three were women. systems,few authors reported research Age of the participants ranged from 30 to on these topics; instead they gave anec- 45 years with a mean age of 38. Number dotal or theoretical information. This gap of years employed in nursing ranged in information provides an opportunity to from 9 to 20 with a mean of 13. Years of contribute to the literature by describing, flight nursing experience ranged from 5 through data, the elements of a high per- to 15 years with a mean of 7.5 years. Primary states in which participants pracformance team encounter. The purpose of this study was to de ticed flight nursing were California, scribe the flight nurses’ perception of the Washington, Vermont, New Hampshire, elements of a high performance team sit- Massachusetts, and Connecticut. Potential participants were identified uation. The qualitative approach provides an opportunity for flight nurses to de- through contact with air medical proAir Medical
Journal
17:3
July-September
1998
Phenomenologic Method Concepts Bracketing The process of identifying and suspending any preconceived notions regarding the phenomenon under investigation Saturation The sense of closure experienced by the researcher when data collection ceases to provide any new information Triangulation The use of multiple methods to collect and interpret data about the phenomenon being studied to arrive at an accurate representation of reality Polit D, Hungler 6. Nursing research: principles and methods. 5th ed. Philadelphia: Lippincott; 1995.
gram managers who gave the names of flight nurses planning to attend the 1996 Air Medical Transport Conference in Fort Worth, Texas. Potential participants were given a telephone presentation of the research project to ensure voluntary participation and verity participants met study inclusion criteria, which consisted of being a registered nurse currently working in the field of flight nursing and employed as a flight nurse for at least 2 years. At the conference, before data co& lection, the purpose of the study was explained to each participant, and informed written consent was obtained. The crew contigurations represented in this study included nurse/nurse, nurse/paramedic, and nurse/respiratory therapist. A crew configuration not repro sented in this sample was nurse/physician, a fact that may be regarded as a limitation of this study. Data Collection Data were gathered by in-depth interviews conducted by the principle investigator. The investigator used bracketing to identify and suspend any preconceived notions regarding the phenomenon under investigation.7 All interviews were tape-recorded. The participants were asked three open-ended questions to elicit information about their experience with a high performance team situation on an air medical transport mission. An 117
interview guide was used to ensure consistency among interviews. The questions were: l Why did you become a tlight nurse? l Describe an experience of a high performance team interaction on an air medical transport mission. l Describe a situation that did not re fleet a hiih performance team interaction on an air medical transport mission. Additional questions were asked to provide clarification and to encourage participants to fully describe the meaning of their experience. The number of participants interviewed continued until saturation was achieved, and data became redundant. Saturation describes the sense of closure experienced by the researcher when data collection ceases to provide any new information.7 When necessary, participants were contacted after the interview so certain descriptions could be claritied. Triangulation, the use of multiple methods to collect and interpret data about the phenomenon being studied to arrive at an accurate representation of re ality,’ was chosen as a method of validating the information obtained in the interviews. The principle investigator observed an air medical transport with two participants. These observations pro vided an opportunity to determine the accuracy of the described phenomenon of the high performance team interaction. A transcript of each interview was made and then analyzed using the phenomenologic method described by Giorgi.8This method involves five steps: 1. After interviews are recorded and transcribed verbatim, data are read in their entirety. 2. Data are reread to identify units in the experience called constituents. 3. Redundant constituents are eliminated, and units are related to each other. 4. Concrete language is transformed into abstract concepts. 5. Insights are structured into meanings of an experience. All data were reviewed for congruency by a researcher experienced in the phenomenologic method. All coded tapes and written transcripts were destroyed after data analysiswas completed. 118
Results Participants described their reasons for becoming a flight nurse. These reasons included role models and experience, an attractive image, opportunity for teamwork and affiliation, autonomy in clinical practice, and the opportunity to make a difference. Most participants were attracted to flight nursing because of exposure to a flight nurse while working in a ground ambulance, the military, or the community. The participants described an image of highly developed communication skills, strong decision-making abilities, professional attitude, and impressive performance. The combination of flying and performing at an advanced practice level with a variety of patients was viewed as an attractive career choice. Working as a team member and team interdependence were identified as positive characteristics of this nursing specialty. The participants identified the flight nurse, paramedic, respiratory therapist, and pilot as the core team members. Other team members were fire department and EMS personnel at the scene and nurses and physicians at referring facilities. Four themes were identified as representative of a high performance team interaction: collaboration, mutual respect and trust, maintenance of fitness standards, and synergy. Each theme will be described in detail. Collaboration. Each flight nurse in the study described collaboration as an essential component of a successfulhiih performance team interaction. Participants reported that team members collectively performed patient assessment, conducted procedures, and developed a back-up plan. Other factors included team members showing respect for others providing care to patients and having a good working relationship. One participant said, “We had a scene flight for a motor vehicle crash victim. An emergency medicine resident was on board as a third crew member. No extrication was involved, so we didn’t have much time to prepare. We made our assessment together, and it was all very quiet and controlled. We decided ahead of time who was going to be the team leader and who was going to manage the intubation, and every person functioned at a high level.”
All participants described a lack of collaboration when discussing a situation that did not represent a high performance team situation. The flight nurses said the team in these situations did not discuss the plan for patient care, stumbled over one another while doing the same things, performed redundant acts that lacked team coordination, and lacked agreement as to who should intubate. Independent actions not involving the team process consistently were mentioned, as well as a lack of coordinated effort. One participant related this story. ‘We were going to a scene call for the victim of a gunshot wound to the head. My partner and I had some complications going in. We got trapped by weather, and we didn’t find the scene right away, so my partner and I were already at a level of frustration before we got on the ground. We were stumbling over each other, trying to back up and get some of the patient report. The patient had become more unstable, and the aircraft we were in was a back-up aircraft that we were not used to working in. The patient was bleeding all over the place, the cuff on the ET tube was tom, and we needed to reintubate him in the aircraft. I thought I should be doing the intubation, and my partner thought he should do it.” Mutual respect and trust. All participants listed mutual respect and trust as part of the high performance team situation. They mentioned confidence in their partner, clinical competence, and knowing one’s practice limitations. Hiih experience and skill levels and the ability to perform quickly and efficiently also were described as ingredients essential to developing respect and trust among team members. One study nurse said, ‘We were dispatched to a serious motor vehicle crash-rollover with ejection of the occupant. The paramedic had immobilized the patient, started intravenous lines, just gotten the patient intubated, and reported that the patient had a tension pneumothorax. We were able to treat the pneumothorax in the helicopter. Both crew members maintain the same level of competency, so that if I were to stop a procedure at some point, my partner could take over for me.”
July-September1998
17:3
Air Medical Journal
Another relayed, ‘We were called to tance of flight crew members meeting the scene of a van rollover with five adult physical fitness standards was menvictims. Two of the patients were unre- tioned because they allowed the team to sponsive and were a distance from one accomplish a flight rescue mission in another. We asked the EMTs to bring which a patient was trapped on the side the patients closer so we could work on of a mountain. In this case, crew memthem simultaneously. Both patients re- bers had to use their physical strength quired intubation. I left my partner with and endurance to hike significant disone of the patients while I loaded the tances while carrying rescue and medother on the helicopter. I felt very conti- ical equipment dent that when he brought the second Additional skills required of team patient to the aircraft, all would be status members were high and low angle rescue quo with the tube position, and every- techniques, both of which mandate a thing would be fine.” great deal of physical fitness. A situation Some participants described a lack of that did not represent a high performance mutual respect and trust in a situation team interaction resulted from inconsis that did not represent a high perfortency in the team members’ commitment mance team interaction. Specific situa- to meeting physical requirements. tions they described included a partner’s Synetgy. Each flight nurse described lack of clinical competence and unful- synergy as the result of a successful high filled expectations of the partner’s perfor- performance team interaction. One elemance. A participant said, “I made an as- ment of synergy included effective comsumption that my partner knew what he munication with team members, which was doing. Had the call happened with developed after working with a partner another partner, it would have gone over time. Communication that did not more smoothly. I was frustrated to think require speaking or only a few words I had to tell him everything to do to keep also was described; in such situations, a the endotracheal tube from coming out.” look was all the communication necesOther descriptions included not giv- sary to orchestrate patient care. ing crew members credit for what they One nurse recalled, “We initiated a knew and sensing that one member did system of monitoring both patients durnot value the other as a team member. ing transport without even speaking. We One nurse said, “We were on a rotary worked for so long together that we flight. I was a fairly new nurse with this knew what the other person was going to flight program, and I was working with do. The care rendered was totally optisomeone I didn’t work with a lot. We mal, and we didn’t compromise in any sitwere going for a really sick diabetic ke- uation; even the pilot had to give report. toacidosis patient who already was hav- Every one of us was doing a job and ing seizures and not doing very well. The knew what we had to do and how we had moment the call came, my partner and I to do it.” Another participant said, ‘mere was were not communicating very well, and things were very disjointed. She had a good communication between us and the lack of confidence in me, and I didn’t prehospital care providers, and there was know her very well. I think that made a lot happening in the helicopter on the things a lot worse. way back. Fortunately, I was working “I was taking report, and she would with a team member I worked with a lot. keep interrupting and asking questions There were several procedures that had that I already had asked. We got back to be done within a l@minute period, and into the aircraft with the patient, and I we got through all those procedures with would do something, and she would to- very little communication. It’s always tally do the opposite. It was just a very good to know that when you finish, you difficult flight because I was angry that know the communication was just about she didn’t trust me to take care of the as good as it could get between you and patient.” your partner.” Fitness standards. Another theme ‘We were on a tixed-wing interfacility identified from the interviews was fitness flight for a trauma patient,” someone else standards. In one situation, the impor- related. ‘When we arrived at the hospital, Air Medical Journal
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we knew we had to intubate the patient. The fact that I and my partner worked so well together, we both kind of looked at each other, and we knew what we needed to do. We both immediately set into action without really having to make a lot of discussion because we had practiced it so much together. We looked at each other, and he immediately got set up to intubate.” Some participants mentioned the role of the pilot. Synergy occurred when the pilot optimized the landing zone to afford the flight crew better access to the patient and a safer landing area, gave report for the medical team, and provided reassurance when he sensed the flight team’s apprehension in dealing with a patient on a long transport A participant said, “We were transporting a high-risk OB patient in preterm labor. We were having a lot of diiculty controlling contractions. We were working so hard with this patient, and the pilot was listening to what we were saying, and he was interjecting his own personal experience, having had a few children of his own, of active labor and how much time you have. He was even doing some of the communications for us to the receiving hospital.” Discussion Weick and Roberts,g who observed and interviewed flight deck personnel on an aircraft carrier for 5 years, describe the collective mind as a theoretical concept that provides a framework for understanding reliable and effective behavior in continuous and critical operating organizations. Continuous and critical op crating organizations, such as air medical programs, require a higher level of interrelating and social skills than efficiencyoriented organizations. The concept of heedful interrelating that Weick and Robert@ discuss coincides with synergy; regardless how visionary or capable one person may be, cooperation with others is imperative to respond to such complex conditions as critical care air medical tEUlSpOIt
Many of the transports the participants described were remarkably similar. Although these flight nurses were not accustomed to referring to themselves as members of a high performance team, 119
they easily understood and described this concept ‘Ihe identified themes were interrelated and led to the ultimate theme associated with a high performance team situation: synergy. Summary This project was designed as a descriptive, theory-generating study to add insight to the developing knowledge base of high performance teams as it re lates to the air medical industry.
Identifying and recognizing the themes associated with a successful hiih performance team should be acknowledged and discussed among tlight team members so that positive patient outcome and work satisfaction can result from the air medical transport experience. Program managers and staff need to be aware of the importance of fostering positive working relationships and buiklii team skills that result in highly developed communication and trust. Attention to
clinical competence and established fitness standards is essential to the process of developing high performance teams. Suggestions for future research include interviewing other crew members who participate in air medical transport to determine the accuracy of the phenomenon described by the flight nurses. Also, identifying and interviewing other high performance teams outside of heath care could be used to validate these findings.
ship. New York: Doubleday; 1993. Bohan G. Building a hiih performance team. Health Care Supervisor 1990;8(4):1521. 6. Vaih P. The purposing of high-performing sys terns. Organizational Dynamics 1982 Autumn: 23-39. 7. Polit D, Hungler B. Nursing research: principles and methods. 5th ed. Philadelphia: Iippincott; 1995.
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National Plight Nurse Association. Standards for flight nursing practice. 2nd ed. St. Louis: Mosby-Year Book; 1995. 2. Blanchard K, Carew D, Parisi-Carew E. ‘Ihe one minute manager build high-performing teams. New York: Morrow & Co; 1990. 3. Mayfield T, Lindstrom A. Medical crew survey. AirMed 19982(5):21-5. 4. Dotithome L The West Point way of leader-
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Giorgi A. Phenomenology and search. Pittsburgh: Duquesne 1985. Weick K, Roberts K. Collective tions: heedful interrelating Administdive science Qmterly
psychologkxl re University Press; mind in organ& on flight decks. 1993;38:35781.
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