Territorial wars, imaginary boundaries and the patient journey

This blog is personal and some will have a problem with me writing about it, truth is I will probably end up in some trouble for posting this.

For most of my career I have had a foot in two worlds.  One world is inside of a hospital as a highly specialised nurse with the other world being out of hospital as an ambulance practitioner.  These worlds are governed by separate bodies with different regulations and scopes of practise.  The sad part is that these governing bodies do not recognise the other’s training, skills or competencies.

For example as undergraduate nurse I had to demonstrate competency in intubation and I had to demonstrate it again as critical care nurse student.  As critical care nurse and educator I have been involved in training paramedics, medical students and nurses to perform this and other skills.  In one of my previous jobs I was required to demonstrate proof of intubation competency on a yearly basis.  However as ambulance practitioner I am not allowed to intubate a patient as the governing body and ambulance act do not recognise my nursing competency or scope of practice.

Recently…in my private vehicle, dressed for a business meeting I came across a patient.  There was an airway problem and there was equipment on scene to intubate and resolve the airway problem.  No one else on scene was skilled to intubate. Just to reiterate…intubation is a skill that I’m deemed competent to perform, it falls within my scope of nursing practice, I have experience executing the skill and I’ve taught paramedics and medical students to perform it.  The problem was that I was in the wrong territory where none of the before mentioned are recognised… yet I treated the patient based on my nursing scope, competencies and also my conscience.

That I resolved the airway issue and that we could now ventilate the patient, appears to be a non-factor…. a formal complaint was laid against me for treating the patient according to my nursing scope in paramedic territory.  I see the enquiry as a suggestion from my paramedic colleagues that the acceptable patient management would’ve been to continue non-ventilating the patient and as such withhold that fighting chance for survival.  Why?  Because of territory…

The irony is…if I did that, if I managed the patient according to my out of hospital (ambulance practitioner) scope, if I did not intubate, if I disregarded my nursing scope, training and experience, the nursing board would’ve (rightfully) take action against me for negligence.

This territorial fight is not ok; it is not ok to say that a patient should rather die than recognise our colleague’s competencies in our territory.

Healthcare is defined as a series of interconnected processes and the end product which is the healthy patient. Are we nurses and paramedics not bound in this definition of healthcare and in the patient journey? If the reason for the existence of the healthcare system is a healthy patient would it not be in the patient’s best interest that practitioners capable of executing a skill being allowed to execute it based on patient requirement regardless of territory?

There seems to be an absolute conviction that healthcare is territorial and divided.  I believe that healthcare is one.  No function in healthcare can stand alone, and neither should they.  When we fight about territories we create barriers between functions that are dependent on each other. The compelling context that glues us together should be the patient and a shared interest in the patient journey.

In healthcare our governing bodies create the boundaries, these are typically functional boundaries.  In other words the boundaries groups specialised functions together to better manage them.   So the boundary of where we practice is actually arbitrary.  And yet, time and again we find ourselves trapped and our patient care crippled by these boundaries and even worse we allow the boundaries to create territories, that is fiercely protected.  It is so fiercely protected that we start believing that it is fair to withhold life saving measures from patients due to functional territory.

Regardless of speciality, field of practice or board that we belong to, we should never settle for less than the best possible patient outcome within our scope and competency regardless of where we are. Because if we don’t, we fail to understand our interdependency.   How can we not share the one goal of health care which is a healthy patient as outcome?

How can any practitioner be conditioned to think that it’s in the patient’s best interest to let them die rather than allow a competent colleague to practise within their territory? Sounds like sick system….


Pre-empting comments on scope:  My scope as per the South African Nursing Council. (http://www.sanc.org.za)   



Critical Care Nursing is care of patients with life-threatening illnesses and injuries and it occurs within a continuum from the scene of initial incident or onset of critical illness such as home through stabilisation, transfer/transportation, emergency and intensive care up to and including transfer to care in lower acuity levels/ step down units.

Specific competencies

2.4.3 Executes airway management in accordance with the patients’ needs or state of respiratory failure, e.g. position, anatomical alignment……….. including intubation (oropharyngeal, nasopharyngeal, endotracheal)

2.4.7 Initiates/performs advanced resuscitative procedures informed by the patient’s cardiopulmonary status and technological parameters, using advanced airway management techniques, cardioversion, defibrillation, external cardiac pacing and emergency drugs, among others, as spelt out in the care management tools such as protocols or Advanced Cardiac Life Support (ACLS) algorithm

Functional boundaries and communication. ICU Congress part 2

It’s the same issues and similar workarounds…in every ICU that I’ve ever worked.  Regardless of hospital, type of ICU, shift or time-lapse between shifts.

One of the biggest failures I’ve observed is the inability to communicate effectively across functions.  This is not restricted to Critical Care; it is a hospital phenomenon.  I think it’s just more obvious in the Critical Care Unit because of the patient acuity and intensity of care. The hospital system lends itself to poor communication via its strict traditional intra- and interdisciplinary lines, complex hierarchies and bureaucracies.  Role confusion and expectations around the behaviours of certain roles creates added inconsistencies to the system.

All of the above is maintained by the way things have always been done, beliefs about self and others, traditions, the stories told in the hospitals and so on.  In short our failure to communicate effectively in health care is due to our culture.  Our culture is created by the stories that we tell.

Each hospital system is divided into smaller, functional parts.  The real strength of the system lies in how these parts can connect seamlessly.  None of the parts can function in isolation.  Persons become trapped within the boundaries of their functions.  If we want to improve patient outcomes and reduce length of stay as a performance indicator, we need to readjust some of the functional boundaries.

How do we renegotiate the boundaries and change the culture?

Strengthening the multi-disciplinary team

In his book the Fifth Discipline, Peter Senge describes a team as:  “a group of people who function together in an extraordinary way- who trusts each other, who complement each other’s strengths and who compensate for each other’s limitations.  To have common goals that are larger than individual goals and who produce extraordinary results.”

I think that we often function as non-teams due to hierarchies and the value placed on autonomy in the health care culture; we prefer the culture of relying on individual expertise. We perform as groups of separate functions working side by side with no shared common goal.  Functioning as non-teams within the system is detrimental to the patient.

Pronovost et al (2003) did a study on the impact of daily patient goals in Critical Care Units.  They created a form that included basic information and questions such as what is the patients’ greatest safety risk today and how can we reduce it?  The form was completed during patient rounds, and signed by all health care workers involved with the patient’s care.  They established a relationship between daily communication and reduced patient length of stay.  Three years later this study was repeated in a paediatric ICU by Phipps and Thomas. They demonstrated that the utilization of daily goals improved the perception of communication and team work.

By applying short term daily goals, a common goal is created, crossing boundaries.  So why are we still so diligently doing separate sets of documentation, duplicating each other’s work and not speaking to each other?  Why are we not sharing daily goals across boundaries?

Team Communication

Effective communication is a prerequisite for team collaboration.  Pronovost et al (2003) estimated that 85% of errors across all industries result due to communication errors.  In health care, poor communication is associated with increased length of stay and error in patient care.

Communication is based on assumptions and we communicate in a way that is self-evident to us.  It might not be self-evident to the receiver.  The use of standardized communication tools can reduce some of the risks and assumptions.  A tool mentioned at the congress is the SBAR method.  (Situation, Background, Assessment, Recommendation).  This method originated in the US navy to provide critical information as fast as possible.  From a nursing perspective I think that often when we call physicians we make assumptions and the physician is left to mind read what exactly is happening. Using a standard tool can reduce the amount of assumptions made.


There was an underlying theme to inspiring ICU…and it was the need to change the culture to allow us to communicate better and work together across functions to improve patient outcome.

And to end with a Francis Peabody quote someone used at the congress:

“….for the secret of the care of the patient is in caring for the patient.”


Phipps, L.M., Thomas, N.J.(2007). The use of a daily goal sheet to improve communication in the paediatric ICU.  Intensive and Critical Care Nursing. Vol. 23 pp. 264-271

Pronovost, P., Berenholtz, S., Dorman, T., Lipsett, P.A., Simmonds, T., Harden, C.( 2003). Improving communication in the ICU using daily goals. Journal of Critical Care. Vol. 18.  No.2. pp. 71 – 75

Senge. P., (1990).  The Fifth Discipline: The art and practice of the learning organization.  Doubleday, New York.

A bad system will beat a good person every time


Remember the broken telephone game where one person whispers something into the next person’s ear and the message is passed through a line of people with the last person announcing the message received. The message has typically changed as words and information is lost (or added) each time the message is passed on.

We play this game in acute care and we call it transitions in patient care whenever a patient is transported from one specialty to another; for instance from an accident scene to an emergency center or emergency center to a critical care unit. The transition is risky, important patient information including baseline presentation and initial management is exchanged in a very short period of time, intuitive assumptions are made about the patient, the transition itself is frequently interrupted and the arrival of the patient in any busy facility will interrupt other tasks, thus the practitioner receiving the handover are distracted by patient load and tasks.

The flow of information during this transition time links the various parts of the greater system involved in time-critical patient care. It is obvious that missing information flows is a common cause of patient error and system malfunction.

There are various variations of the added poster and they all imply segregation of the acute care team. It is a symptom of a culture that needs a shift so that we can improve transitions of care.

Culture is the way that things are done and it is the result of all the daily conversations, negotiations, habits, traditions and stories told to each other while at work. These shared assumptions are considered valid and are continuously reinforced through behavior and attitude.

The culture of an industry, organization or unit is an important leverage point within a system and is a strong indicator of the strength of linkages and flows between subsystems. A poster like this implies a certain mind set about team approach, team dynamics and views on the role of other functions in this case paramedics. It makes a statement about the openness within the unit to learn through cross pollination from other functions.

Am I reading too much in a mere poster? I think not, with years of diverse experience across the acute care system this is just one example of the consistent messages within the system.

I could’ve easily reversed this example to implicate other members of the acute care team as the culprits of poor cultural behavior. However it is not about which example is used, it is about what these examples signify about the health of our industry’s sociocultural behavior, the unwritten rules within the system and how it harms the core function of what we are trying to achieve.

We are often so blinded by our function that we completely miss the bigger picture and how care transcends from one area to the next. None of us function in isolation, we are all linked and if we complicate another team member’s function it boomerangs and complicates our own function.

This poster is merely a conduit demonstrating the culture, how we do things and treat each other. These examples represent a culture that discourages adequate care and that is damaging to the linkages between subsystems.

The problem with this behavior
– It creates silos or barriers resulting in providers that should be working towards the same goal (rendering emergency care to the best of our ability) to work against each other.
– Segregating the functions may result in providers attributing vital patient information as unnecessary and providers may be ignorant of the value of the information exchanged. There is a saying that we don’t know what we don’t know. An example of such behavior is when emergency center providers tell paramedics that they are not interested in information including structural damage to a vehicle, why the patient is immobilized or why certain decisions in management was made etc.
– This poster is the result of the parts (or functions) in a system not understanding the binding context for working together. This poster and behavior basically obstructs members in the same team from performing their tasks. Without understanding the context there is no direction and we harm patients.
– It prevents knowledge generation. Healthcare facilities are organized around functions with numerous transitions in care and a variety of tasks occurring simultaneously. One of our biggest challenges is the lack of reliable feedback mechanisms and knowledge to integrate all these functions into a coherent whole. We need to improve relations with our actions, not make it worse.
– The acute care system is a complex system facing an unpredictable demand within a time critical frame. Such a system can easily be overwhelmed leading to chaos without adding stress to the system, to the team dynamics, and additional stress on transitions or risky situations. The outcome of not working together is degradation of overall performance, patient error or harm and a negative impact on system effectiveness.

What can we do to improve the transitions of care?
– Be more systematic and intentional about improving team work. Remove the posters and refrain from destructive comments. Try to understand other team member’s functions and how it impacts on your function.
– Go back to basics, what is the core function of an ambulance service? What is the core function of the emergency center? When our behavior hampers the ability of another link within the acute care services to meet their core function we decrease our effectiveness and ability of our entire system.
– Do not disregard the emotions evoked by exposure to these posters and messages. It impacts the lines of communication of persons working within the unit and those entering the unit.
– Understand that the entire health sector is overstretched and understaffed. Within the health sector, the acute care system functions within unpredictable demand and time critical intervention. It is only by having insight and working together that we can improve patient outcomes and our work conditions.
– Communicate and share stories with members of the other parts of the system, discover the shared purpose, create a collective intelligence and craft effective coping strategies for all.
– Create a culture that embraces the concept of psychological safety enabling everyone within the system a voice and ability to perform their function. Interaction is the key to successful transitions in care.
– Accept that some tensions across the boundaries are ok and used it to improve the collective performance and thus patient care.
– Look at the bigger picture whatever the facility policy; it has an impact on patient care in a wider context. Example, by banning the ambulance from being calling free at your facility because they have to drive to another facility to discard medical waste and clean their equipment, prohibits them from responding to priority calls which negatively access to care

It is mind boggling to even consider the complexity added together when the broken, injured human organism with interconnected body, mind and spirit enters the complex, multifunctional acute care system. I don’t think we need to add a broken acute care system to aggravate chaos.

The parts of the acute care system should not be blinded by a single minded linear function. We need to share knowledge, insights and stories to create overlaps and a culture of collaboration as survival skill in the ever changing landscape that we work in. By creating overlaps we create the ability to gain knowledge and to survive.

Inadequate information flows and missed feedback is common causes of system malfunction. So let’s remove the posters and behaviors that highlight dysfunctional relationships.

Note on the terminology acute care as opposed to emergency care. According the World Health Organization definition of Acute Care it includes emergency medical care, trauma care, pre hospital care, acute care surgery, critical care, urgent care and short term inpatient stabilization.


Generating knowledge in health care

Hospitals are organized around lots of functions. In such a complex system with numerous functions and actions all happening at the same time our biggest challenges is the lack of reliable mechanisms and knowledge to integrate all these functions into a coherent whole.
We tend to become our position and function and we may be blinded to how our function is affecting someone else’s function. We are so busy fighting our own battle that we are not seeing the big picture unless we learn to look for it.
This is aggravated by health care services traditionally being a culture of existing individual experts (silo’s) where knowledge is not typically shared across the boundaries. (Think surgeon’s vs anesthetists vs physicians). And hierarchies
Often when we are confronted with limitations within the functions of our field of expertise, we have an assumption that fixing or providing the ideas is the function of another department, our supervisor, hospital management etc. Not us, we don’t give ideas. We sometimes forget that we all serve each other – department for department and function for function. Think about a problem that your department has simply been “working around” because you have only been working towards meeting the patient’s immediate needs within your department.
Health care needs to start sharing knowledge, insights and stories to create overlaps. These overlaps creates the ability to gain knowledge, to be informed of what other departments within our organization are doing (hospital/ ambulance service) and to share our stories to drive innovation.
In my experience there is an abundance of good ideas in our health care organizations, sadly though they are often dismissed as soon as they are shared with all the reasons why it won’t work. We need to change our stories and our language to overcome these barriers so that we can become nurturing towards good ideas.