patient safety issues rapid response teams …ajcc.aacnjournals.org/content/22/3/198.full.pdftrends...

Notice to CNE enrollees:A closed-book, multiple-choice examination following this article tests your under standing ofthe following objectives:

1. Identify 5 categories that encompass teameffectiveness.

2. Discuss the components of an effective rapidresponse team (RRT).

3. Describe potential barriers to implementationof an RRT.

To read this article and take the CNE test online,visit www.ajcconline.org and click “CNE Articlesin This Issue.” No CNE test fee for AACN members.

By Linda Searle Leach, RN, PhD, NEA-BC, CNL, and Ann M. Mayo, RN, DNSc

Background Multidisciplinary rapid response teams focus onpatients’ emergent needs and manage critical situations toprevent avoidable deaths. Although research has focused pri-marily on outcomes, studies of the actual team effectivenesswithin the teams from multiple perspectives have been limited.Objective To describe effectiveness of rapid response teamsin a large teaching hospital in California that had been usingsuch teams for 5 years.Methods The grounded-theory method was used to discoverif substantive theory might emerge from interview and/orobservational data. Purposeful sampling was used to conductin-person semistructured interviews with 17 key informants.Convenience sampling was used for the 9 observed events thatinvolved a rapid response team. Analysis involved use of aconcept or indicator model to generate empirical results fromthe data. Data were coded, compared, and contrasted, and,when appropriate, relationships between concepts were formed.Results Dimensions of effective team performance includedthe concepts of organizational culture, team structure, expert-ise, communication, and teamwork.Conclusions Professionals involved reported that rapid responseteams functioned well in managing patients at risk or in crisis;however, unique challenges were identified. Teams were looselycoupled because of the inconsistency of team members fromday to day. Team members had little opportunity to developrelationships or team skills. The need for team training may begreater than that among teams that work together regularlyunder less time pressure to perform. Communication betweenteam members and managing a crisis were critical aspects ofan effective response team. (American Journal of CriticalCare. 2013;22:198-210)

RAPID RESPONSE TEAMS: QUALITATIVE ANALYSIS OF

THEIR EFFECTIVENESS

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©2013 American Association of Critical-Care Nursesdoi: http://dx.doi.org/10.4037/ajcc2013990

Patient Safety Issues

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Teams are more than a group of individuals whocome together acting independently of one another.5

Teams are 2 or more persons who have shared goalsthat inform their individual and collective actions.Teams consist of individuals who have roles withinthe team, carry out interdependent tasks, share com-mon goals, and are able to adapt to changes in theenvironment.5 Multidisciplinary teams have been inves-tigated in operating rooms,6-12 critical care units,13-18

and emergency departments.19 Each study revealedbarriers, including difficulties with team formation,variation in shared understanding of purpose androles, communication breakdowns, and power andhierarchy interference with collaboration. Theseteams routinely face the challenge of managing apatient’s crisis and working in critical situations.

Crisis management creates circumstances ofrisk or high stakes because the crisis creates a con-text of uncertainty, time pressure, and knowledgethat decisions are often irreversible. Situations suchas these, with the expectation that knowledge andclinical expertise will be applied to successfullymanage critical situations, demand effective teamperformance. Because of interdependence, effectiveteam functioning means that the team’s tasks arecoordinated, and cooperation is inherent becausethe work cannot be successfully accomplished byindividuals working in isolation.

Concerns about patients’ safety in acute carehospitals in the United States led to national patientsafety initiatives4,20 to reduce adverse events and, specif-ically, to prevent avoidable deaths among hospitalized

patients. One initiative was the creation of rapidresponse teams (RRTs), also called medical emer-gency teams. These crisis management teams weredesigned to rescue patients by preventing cardiores-piratory arrests that occurred outside intensive care.The RRT is a resource that can be called on to inter-vene early enough in the clinical course of patientswho are experiencing signs and symptoms of com-promise to prevent further deterioration in thepatients’ clinical condition, adverse outcomes, andpreventable deaths. Team composi-tion is multidisciplinary; teams typi-cally include a registered nurse, arespiratory therapist, and a physician.

Before use of RRTs, the usualapproach to a patient crisis was an adhoc, individual search for neededresources or for a cardiac arrest team.The advent of RRTs has changed theresponse from a critical-situations approach to asystems approach that is coordinated and opera-tional at the level of the patient and the health careprovider.21 Most of the research on response teamshas focused on tracking and reporting the hospitaloutcomes. Findings have been mixed. Most of thestudies, starting with the research by Lee et al,22 weredone at a single site and involved use of historicalcontrols; the results included fewer cardiopulmonaryarrests (codes) and lower mortality rates after imple-mentation of RRTs.22-42 In contrast, beginning withthe Medical Emergency Response ImprovementTeam study,43 code rates and mortality rates werenot significantly reduced, although some downwardtrends were noted.43-45 In a meta-analysis of 18 studies(1950 through 2008), Chan et al46 reported mixedfindings. Rates of cardiopulmonary arrest outsidethe intensive care unit (ICU) in adults were reducedby 33.8% (relative risk [RR], 0.66; 95% CI, 0.54-0.80),yet the rates were not associated with lower hospi-tal mortality rates (RR, 0.96; 95% CI, 0.84-1.09).The reduction in the rate of non-ICU cardiopulmonary

As the coordination of work in organizations has become more complex, teams andteamwork have become necessary to accomplish organizational goals.1,2 High-riskenvironments such as nuclear power plants and naval aircraft carriers have pio-neered a path to achieve optimal levels of safety via high-performing teams.3 Inhealth care, the tradition of relying on individual clinicians and individual expert-

ise has changed to relying on team-based delivery of care to ensure expected outcomes. Effectiveteam functioning was one principle emphasized as necessary to create safe hospital systems.4

In acute care hospitals, increased complexity and interdependence amid the need for efficiencyhave accelerated a focus on the advantage of teams, teamwork skills, and team training.

About the AuthorsLinda Searle Leach is an assistant professor, School ofNursing, University of California Los Angeles, Los Ange-les, California. Ann M. Mayo is a professor, Hahn Schoolof Nursing and Health Science, University of San Diego,San Diego, California.

Corresponding author: Linda Searle Leach, RN, PhD, NEA-BC, CNL,

UCLA School of Nursing, 700 Tiverton Factor Bldg, LosAngeles, CA 90095-6917 (e-mail: [email protected]).

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Effective teamfunctioning isnecessary tocreate safe hospital systems.




MethodsIn this descriptive qualitative research study, a

grounded-theory method was used to describe theperceptions and observations of RRT events as theevents occurred in the natural setting. A total of 1to 2 investigators were on site at any time, depend-ing on the availability of the individual investigators.Grounded theory was used to illuminate the socialand technical process of a multidisciplinary healthcare team and the members’ interactions in order toexplain the subjective aspects of team-based care deliv-ery and participating as an individual on the team.

Data sources for the study included field notesfrom observed RRTs, hospital documents, and tran-scripts from recorded semistructured, individualinterviews. Data collection and analysis were con-current with the use of theoretical sampling to iden-tify specific ongoing data sources, such as participantsfor interview or in-service orientation curricula.Because RRTs are not planned events, neither theevents nor the team members could be preselectedor randomly selected for this study. Data were codedin a 2-step process. The first step, termed open coding,involved coding the data as they were being col-lected. This step resulted in numerous categories.The second step, termed axial coding, was to exam-ine those initial categories for similarities. Wheresimilarities existed, those first-step categories werecombined into fewer more comprehensive cate-gories. Theoretical saturation of categories wasdetermined when no additional data were beingfound to develop properties of any new codes oraxial relationships between codes.

Approval for the study was obtained from theinstitutional review boards of the study site and theUniversity of California, Los Angeles. Participationby RRT members, staff registered nurses, and otherprofessionals involved with RRTs was voluntary,and informed consent was obtained.

SettingThe study was conducted at a large, public, uni-

versity-affiliated medical center in northern California.This hospital was purposefully selected because it wasidentified in a previous study48 of RRTs in 6 hospi-tals as an exemplar hospital with an organizationalculture that supported the introduction of the RRTprocess. Primary factors in the selection were theorganization’s commitment to innovation to achievesafe care and improve patient safety and the staff’sacknowledgment of the original finding.45

With more than 6000 employees, the medicalcenter is a large public, tertiary care, university-affiliated teaching hospital. It is a safety-net facility

arrests for children was 37.7% (RR, 0.62; 95% CI,0.46-0.84) and was associated with a 21.4% reduc-tion in hospital mortality rates (RR, 0.79; 95% CI,0.63-0.98), but the mortality rate was not a strongfinding. No further meta-analysis for the years after2008 has been published, and no multicenter clinicaltrials have been reported. Despite the mixed findings,hospital leaders have not actively questioned the useof RRTs. Rather, current discourse on RRTs is that theteams are valued because early recognition of patientsat risk is important for patient safety.47 In order tosupport such efforts, bringing a team of experts to thebedside to prevent adverse events such as cardiores-piratory arrests makes sense. And, RRTs require onlymodest resources to prevent escalation of deteriora-tion in a patient’s condition and the need for transferto intensive care.47

RRTs do their work within an organizational cul-ture. Unfortunately, much remains unknown aboutorganizational structures and RRTs.47 For example,knowledge of a team’s performance, including howteamwork develops, is applied, or evaluated and theextent to which team debriefing is used, is limited.No research on work coordination or on relationalinfluences on communication, trust, and respectamong the members of RRTs has been reported.Because of the social nature of organizational cul-tures, a broader range of methods to generate knowl-edge about complex organizational relationships isrecommended.47 Specifically, use of an RRT is a com-plex intervention involving organizational, political,cultural, and financial factors and a system of complexhuman activities for which the traditional scientific

method of randomized controlledtrials is not possible or recommended.29

Therefore, descriptive studies, caseand observational methods, as wellas qualitative methods are most use-ful.47 Health care leaders need anunderstanding of how members of anRRT work together as a team and howmuch teamwork influences perform-ance. Investigating RRT performancein the context of organizational socialprocesses provides the opportunitynot only to elucidate team perform-

ance but also to better understand the social processesin operation that may or may not affect a team’seffectiveness. Because no research was available onthis subject in the context of an organizational cul-tural social process, we used a qualitative method todescribe the effectiveness of RRTs. The associatedresearch question was, How does a rapid responseteam function effectively?

Research onrapid response

teams andimproved hospital

outcomes hasyielded mixed

findings.

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for the county and a regional resource for specialtycare in burns, trauma, and spinal cord injury. Thepatients are primarily low income, and 85% ofpatients do not have private health insurance.

Sampling Method and SampleA convenience sample for RRT observations

was used because the timing of events that requiredan RRT was unpredictable. Because of differences inavailability of the investigators, 1 investigator (L.S.L.)observed 3 RRT events and 2 investigators (L.S.L.,A.M.M.) observed 6 RRT events for a total of 9 obser-vations that were made on different days of the week(Sunday, Monday, Tuesday, and Wednesday) duringa 30-day period in August and September 2008.

Initially, purposive sampling was used to iden-tify hospital documents that needed review. A previ-ous study48 of 6 hospitals in which nurse leaders andeducators from the study site participated in inter-views indicated which hospital documents were rele-vant to the design and ongoing monitoring of RRTsand patients’ outcomes. The documents includedRRT training materials, a log of RRT calls, an RRTdocumentation template, and a job description forthe registered nurse members of the RRT. Theoreticalsampling of documents occurred as the study pro-gressed, leading to, for example, examination of docu-ments of the RRT quality improvement committeethat provided information on decision makingabout changes in RRT processes. Again, purposivesampling was used initially to identify key inform-ants for interviews. The 2 categories of informantswere RRT members and hospital administrativeleaders involved with implementing the use of RRTs.The final interview sample size was 17 and includedregistered nurses who called an RRT, nurses whoresponded as members of the team (RRT nurse),physician members of the team (hospitalists), andadministrators, including the department heads ofrespiratory therapy, nursing, and medicine. Theoreti-cal sampling of participants informed the addition ofmore RRT nurses because the nurses had more expe-riences with RRTs than did any other RRT members.

Data CollectionThe research question, How does a rapid response

team function effectively?, framed this qualitativegrounded theory study. Both study investigators(L.S.L. and A.M.M.) conducted individual interviewsand observations. Each investigator has medical-surgical and intensive care nursing backgrounds andhas had leadership roles in both areas.

Interviews. Interviews with RRT members andhospital leaders associated with the introduction of

RRTs and training of RRT members were conductedin a private setting in the hospital. Two categories ofparticipants were involved in face-to-face, individualinterviews. Real-time interviews after events thatinvolved an RRT were conducted with the responseteam members, who made themselves available forinterviews, and system level–focused interviews wereconducted with hospital administrative leaders. Forexample, RRT members who were interviewed includedbeside nurses who called for an RRT and RRT nursesand hospitalists who responded to those calls. Ques-tions for these participants focused on the team’sstructure, effectiveness, and communication. Con-ducting research interviews immediately after an RRTevent gave insight into RRT members’ perception ofthe team’s performance but limitedthe availability of 1 group of teammembers (ie, respiratory therapists)because of workload issues.

Interviews with a nurse executive, amanager of the RRT, several physicianleaders, and a quality improvementadministrator were conducted for theprimary purpose of learning aboutadministrators’ expectations of RRT per-formance. The administrators were specifically inter-viewed about their expectations of RRTs’ performanceand the contributions of the various team membersto the team’s performance. Interviews were digitallyrecorded and were transcribed later for analysis.

Observations. Observations of actual RRT eventswere conducted in patients’ rooms and hallways asthe events unfolded. The focus of the study observa-tions was the functioning of each team member inhis or her specific role and the interactions of the teammembers as the RRT event progressed. Field noteswere taken for each observation to record activities,individuals involved (eg, RRT members, other careproviders, and the patients), location of team mem-bers in the room, actions taken, team interactions,communication of information, and how the patients’crisis or the reason for the RRT was resolved.

Hospital Documents. Data from hospital docu-ments were collected as field notes. The data gatheredincluded the training content presented and infor-mation disseminated about RRTs during implemen-tation of the team; frequency and reason for the RRTcalls; sample documentation forms used to recordpatient care and assessment during an RRT event; andhiring criteria for RRT nurses. Hiring criteria wereincluded because the RRT nurses were the only teammembers hired exclusively for the RRT. Selection ofthe hospital documents was based on data from theongoing interviews with the participants in the study.


Nine rapidresponse teamobservationswere conductedin a 30-day period.




ized by dedication to their institution’s teachingpurposes, and focused on patients and the chal-lenges associated with the care the participants pro-vide. Participants said that they carry out their workin a context infused by the pursuit of innovation tocontinuously improve quality and safety. The cul-ture was typically described as follows: “Peoplewho work in this hospital are really aware of ourmission and they are committed to care for ourpatients and to our purpose.” One participant com-mented, “This is a very collegial kind of teachingenvironment.” Additional descriptions included thefollowing: “We’re all focused on the patient andwhat we ought to do . . . .” “Our mission makesmost of our teams very effective . . . .” “This is ateaching hospital . . . it’s a teaching learning organi-zation that is involved with the Institute for Health-care Improvement. . . . There is a tendency to wantto be front wave and there is a status associatedwith being known for that.”

Organizational leadership support. The categoryorganizational culture includes the subcategoryorganizational leadership support. Participantsdescribed a need for leadership and active supportfor change when innovations in care delivery areintroduced. They conveyed that patient safety was arecognized priority and that organizational resourceswould be applied to achieve successful approachesto patient care. Organizational leadership supportmeant backing and reinforcement from administra-tive and clinical leaders to organize and manage thedevelopment and use of an RRT. Typical commentswere as follows: “Administrative leadership providessupport, and I think that is what has created team-work between RRT members and the staff.” “Lead-ership is very important; it’s critical. I don’t think itwould get off the ground if you didn’t have thatsupport. When issues come up, there is less willing-ness to deal with it if you don’t have leadershipsupport.” “The goal is to improve patient care andto facilitate processes in which the patient can getoptimal care.”

Team StructureTeam structure includes the function of an RRT,

the design of the team, and the description of therole of each team member. Participants describedan RRT as a mobile team that responds rapidly atany time of the day, 7 days a week, to a bedsidenurse’s request for assistance with a patient whosecondition might be worsening. Team members wereexpected to respond to the RRT call within 5 minutesand to work with the bedside nurse to determine andaddress the patient’s needs. The responsibilities of

Data collection ceased when saturation wasreached, that is, when data from participants, obser-vations, and documents had become repetitive interms of contributing to any new categories.

Data AnalysisOn the basis of the grounded theory method,

data collection and analysis were ongoing, allowingrefinement of interview questions and explorationof emerging categories of data. Data were handledby using open and axial coding and an iterativeconstant comparison to compare, contrast, and categorize data.49 Both study investigators read tran-

scripts independently and thencompared codes to identify simi-larities, differences, and patternsuntil categories were agreed on. In addition to the interview tran-scripts, detailed notes from fieldobservations were coded and inte-grated into this analysis phase ofthe study. In order to enhancecredibility, the categories andcodes were shared with an audi-ence of nurses (bedside and RRTnurses from the study site) along

with an abstract representation of the RRT’s per-formance. The members of this audience confirmedthat they recognized the experience from thedescription presented.

ResultsFive categories were identified as important in

the description of the effectiveness of an RRT. The Table gives the categories and the subcategories.

Organizational CultureThe participants in the study described their

organizational culture as mission driven, character-

Patient safety wasa recognized prior-ity and resources

would be applied toachieve successful

approaches topatient care.


Table Categories and subcategories of responseteam effectiveness

Organizational leadership support

SurveillanceLeadership

Clinical knowledge and experienceManaging a crisis

Shared purposeFamiliarityCollaboration/conflictTraining

Organizational culture

Team structure

Expertise

Communication

Teamwork

Category Subcategory




the RRT nurse included developing a plan of actionwith the bedside nurse, the respiratory therapist,and the patient’s intern and/or resident to stabilizethe patient’s condition, assisting with implementa-tion of the emergent plan, and completing documen-tation on the RRT form. The goal of the responseteam was to prevent further deterioration in thepatient’s clinical condition, improve managementof patient care, and determine the level of careneeded to address the patient’s clinical situation.The mean number of RRT calls had been about 790annually during the past several years, a mean of70 calls per month or approximately 2 calls per day.

Each RRT includes an RRT nurse, a bedside nurse,a respiratory therapist, and the patient’s primaryphysician intern and resident (house staff). The RRTnurse is an ICU-trained nurse who is a resource forthe various nursing needs due to emergency andunpredictable situations. The RRT nurse is a dedi-cated position; that is, the nurse’s main job functionis to respond to RRT events. Nurses were hired forthis position to specifically carry out the duties ofan RRT nurse, and 1 to 2 RRT nurses are present oneach shift. A dedicated RRT nurse is in contrast to anurse of the ad hoc, rotational model, in which anurse with a primary role responsibility in anothercapacity, such as charge nurse in an ICU, is calledupon to respond to the RRT call. The 24/7 serviceprovided by hospitals results in rotations of healthcare providers who may work 3 or 4 shifts in a rowand then be off for 2 shifts. Therefore, the same RRTnurse will not respond to every RRT event. However,with a dedicated position, a finite core group of 9nurses are RRT nurses. An RRT nurse is not assignedto a specific unit or area for patient care and doesnot have assigned patients. The nurse’s primaryactivities are to respond to RRT events, performrounds (to recognize potential decline of patientsearly and preemptively identify patients at risk) whennot responding to RRT events, and function as therecorder during any cardiopulmonary arrests. Thestudy participants all agreed that to fulfill this role,a nurse must have had critical care experience andfundamental skills in critical care. Team structure had2 subcategories: surveillance and team leadership.

Surveillance. RRT nurses were actively engagedin surveillance to identify patients at risk for com-plications or for becoming seriously ill. This surveil-lance is a primary function of their role on an RRT.Participants in the study talked about how RRTnurses collaborate with the bedside nurses on eachpatient care unit by making rounds regularly twiceeach shift and additionally as needed. Rounds wereused for consultation, and the RRT nurses reported

that bedside nurses invite involvement of the RRTnurses in a dialogue about at-risk patients. A bedsidenurse said, “The RRT nurses are good at identifyingpotential problems and the rounds support that.”One RRT nurse explained, “I make rounds withthem [bedside nurses]—they’re comfortable andable to come to me and discuss [concerns aboutpatients] without feeling intimidated.” Surveillanceby RRT nurses led to a change in the conversationsbetween bedside nurses and RRT nurses. Bedsidenurses thought that the consistent and routine pres-ence of RRT nurses and the RRT nurses’ support, clin-ical knowledge, and expertise engendered trust andfamiliarity. Another RRT nurse stated,“They recognized that you know howto help them.” In this way, an RRTnurse is a resource to a bedside nurse,and the collaboration of the 2 nursespromotes their ability to worktogether when a patient crisis occurs.

Leadership. Study participantsdescribed their RRT as nurse led, withthe goal of bringing critical care nurs-ing expertise, at any time, day ornight, to the bedside of patientslocated outside the ICU who haveearly indications of a deterioration intheir condition. The response teamassists the bedside nurse and thephysician in assessment, intervention, stabilization,and, if needed, transfer to a higher level of care.Participants thought that team leadership wasgrounded in the organizational values embodied inthe mission, as expressed in this quotation, “Theteaching mission contributes to the team workingtogether; people who work in this hospital are reallyaware of our mission and they are committed tocare for our patients and to our purpose.”

Team leadership was evident and was providedprimarily by the RRT nurse and the physician. Lead-ership was dynamic between these 2 members andreverted to one or the other during the RRT inter-vention. The RRT nurse usually led the team at thebeginning of the RRT event and at the end of theresponse. The responding physician, upon arrivaland during the event, assumed leadership, particu-larly in verbal orders for treatment of the patient.

Study participants varied in their responsesabout who led the RRT. RRT nurses indicated thatthe team was nurse led and that the RRT nurse wasthe leader. The RRT nurses led by “being advocatesfor our patients, getting the patient to relax, teachingthe staff, guiding the physician, and making surethe patient is safe.” Several physicians concurred,


The rapidresponse team is nurse-led, withthe goal of bring-ing critical carenursing expertiseto patients outsideof the intensivecare unit.




crisis as being aware of urgency and time pressuresyet taking speedy actions to meet a patient’s needs.

Participants said that to manage a crisis, teammembers need to “be confident in their skills and judg-ment and project that. . . . Be calm about it, not screamand yell but direct things in less than an ideal situa-tions. Manage problems . . . find out what is going onand look at the facts . . . working toward a solution.”An RRT nurse said, “Effective team members are able tofocus on the crisis, to manage the crisis to prevent fur-ther deterioration, and to prevent an adverse event.”

CommunicationCommunication included seeking and reporting

information. During RRT observations, communica-tion was both verbal and nonverbal and informal andstructured. Structured communication was the typetaught and practiced during RRT orientation. For exam-ple, bedside nurses provided a structured patientassessment to the RRT nurse upon the nurse’s arrival.

The importance of communication was discussedin relation to the team’s effectiveness. For example,poor communication (eg, when the bedside nurse didnot provide a problem-focused assessment) resultedin lengthy exchanges between members of the RRT toextract relevant information, thus slowing the team’seffectiveness in making timely decisions. One partici-pant described effective communication as “the styleof response is one that allows people to give informa-tion and doesn’t shut them down . . . being an infor-mation gatherer and willing to have a dialogue.”Participants identified issues with communication inthe context of communication among members ofdifferent disciplines: “Communication is definitelythe No. 1 issue and the key to a multidisciplinaryapproach.” “The only barrier I think is figuring outpeople’s roles; when people come in the room theydon’t introduce themselves or tell you who they are.”Communication was at its best when individualteam members, regardless of the member’s position,were perceived as not intimidating and the dialoguewas focused on the patient.

TeamworkTeamwork was most often discussed and observed

as coordination among team members workingtoward the common goal of addressing a patient’simmediate needs. Teamwork was viewed as workingwell together, having an understanding of the purposeof an RRT and the reason the members came togetheras a team. Training in teamwork was considered desir-able. RRT members identified being familiar with oneanother, in particular being familiar with and trustingthe RRT nurses and knowing one another, as important

but a few participants said the physician was theleader of the RRT. However, observations of RRTinterventions revealed that the leadership wasshared and further clarified that the RRT nurse ledthe initial response to the call for assistance andthat the resident or intern had a leadership role inordering medication, laboratory tests and studies,and other treatments for the patient.

ExpertiseExpertise was discussed by participants as foun-

dational to carrying out the RRT’s purpose of rescu-ing. Expertise meant being highly skilled, using aproactive approach by making rounds to identifyat-risk patients early, being good at identifyingpotential problems, and being able to rapidlyrespond (within 5 minutes). Additional descrip-tions included excellent assessment skills and abil-ity of team members to focus on the crisis andmanage it to prevent further worsening of apatient’s condition. Expertise incorporated knowl-edge, skills, and characteristics identified as neces-sary for the individual team member. Expertise had2 subcategories: clinical knowledge and experienceand managing the crisis.

Clinical Knowledge and Experience. Participantsdescribed expertise as clinical knowledge and expe-rience and said these were necessary to respond tothe patient’s situation and to provide a basis (foun-dation) for a team member’s clinical judgment andreasoning. Clinical knowledge was described as “ableto assess the patient quickly; excellent assessment

skills applied very rapidly.” Experi-ence was also identified as a com-ponent of credibility within theteam. One participant said, “Teammember experience is importantfor their ability to rapidly identifyissues and is a critical factor in theteam’s acceptance of that mem-ber.” Clinical knowledge and theability to make decisions on the

basis of previous experience were then applied inmanaging the crisis. As one RRT nurse said, “Aneffective team member is able to apply their knowl-edge and expertise to anticipate patient needs, iden-tify risks . . . assess and monitor the patient.”

Managing the Crisis. Managing the crisis wasdiscussed as a necessary dimension of expertiseamong team members, specifically, that clinicalexpertise, knowledge, and experience alone werenot adequate. Team members also must have addi-tional knowledge, skills, and experience in manag-ing a crisis. RRT members described managing the


Expertise was discussed as foun-dational to carryingout the team's pur-pose of rescuing.




contributors to the team’s performance. RRT nursesand bedside nurses discussed knowing one anotheras something that had evolved since the time theRRT was established and, more importantly, fromwhen the daily rounds by the RRT nurses began.This regular and consistent connection fosteredfamiliarity and trust. Subcategories of teamworkwere shared purpose, familiarity, collaboration/con-flict, and team training.

Shared Purpose. Shared purpose was describedas knowing what the team was expected to do andwhy the team was constructed. This subcategoryreflected collective knowledge about the reason thatuse of an RRT was developed and implemented andthe overarching goal of patient safety. A typicalcomment was “The team has a shared understand-ing or collective agreement on what their purposeis and how to go about achieving it.” Another par-ticipant said, “I think people believe in what we’redoing. . . . we all have the same goal.”

Familiarity. Familiarity meant knowing oneanother. Participants in the study described this aspectof teamwork as being familiar with one another, rec-ognizing members of the RRT, and having workedwith one another previously. Familiarity was con-sidered important because it enabled trust. Onephysician member of an RRT said, “I think it helpsbecause you know what to expect, you have certainexpectations. I know who has certain strengths.”

Events that required an RRT were perceived asevents that called for time-pressured, time-sensitiveresponsiveness in an urgent situation. Although notall RRT events were critically urgent, the underlyingpremise of time urgency added to the importance offamiliarity among the team members. Introductionsand role descriptions were kept to a minimum; RRTmembers focused on addressing the patient’s situa-tion and immediate needs. The members had littleif any time to establish relationships and develop trustin such situations. Familiarity served as a bridgethat promoted trusting behaviors when urgency andtime pressures took precedence. One RRT membersaid, “That made a big difference because we’veworked with each other before.”

Collaboration/Conflict. The study participants saidthat collaboration meant cooperation, coordination,and willingness to work together. They thought thatthese qualities were reflected in attitudes and behav-iors of the RRT members and said, “The ability toanticipate and collaborate with your team members. . . not individuals making decisions. It’s a collabo-rative decision.” A typical RRT nurse comment was“We are not afraid to discuss or have conflict. . . . wecoach . . . give a lot of input. . . . we’re here to help

out for the patient and for nurses at the bedside.”In contrast, conflict relative to cooperation and

collaboration was described as occurring with theinterns and residents during the initial phase ofimplementing use of an RRT. Members of the RRTdescribed barriers as a disruption to the traditionalrole expectations of the physician of being incharge. The study participants discussed the atti-tudes held by these physicians during this initialphase that conveyed a sense of failure if an RRT hadto be called. A bedside nurse reported, “The housestaff would tell the nurse, ‘Don’t youdare call an RRT or I’ll report you.’”

The leadership role of the RRTnurse was described as threatening tothe house staff because the RRT nurseshad learned during training to assumeresponsibility for the patient. Oneadministrator said, “We were havingproblems with at least a handful ofresidents. Some of the house staff feltpretty threatened.” Another adminis-trator said, “There have been a few instances wherephysicians resisted RRTs being called on theirpatients but that has been worked out; when issuescome up, they are addressed.”

Training. The study participants described RRTtraining as a 1-day educational program for nursesthat focused on conditions likely to lead to deterio-ration in a patient’s clinical condition, such as strokeand sepsis. Communication was included as a topic,but the focus was on structuring the communicationby using the technique of situation, background,assessment, and recommendation. This training wasfor nurses involved in the RRT. Physicians involvedin implementing use of an RRT provided the lectureson the early recognition and management of criticalsituations, but no physicians attended the lectures aslearners in RRT training. Training to promote com-munication, collaboration, and a team orientationamong nurses, physicians, and respiratory therapiststogether was not provided. One physician leaderdiscussed how the physicians were prepared forRRTs: “They [residents] go through a couple of ori-entation RRTs, sort of learning on the fly as well. . . .We do a more formal orientation to RRT . . . 1-hourconference . . . present the data in terms of the goodeffect it has had.”

The study participants identified future trainingneeds that included a focus on communication; usingsimulation; and bringing individual nurses, physicians,and respiratory therapists together. RRT memberscommented on the need to have individuals fromthe involved disciplines interact in learning about


Team familiaritypromotes trustingbehaviors whenurgency and timepressures takeprecedence.




consistent with findings from studies of otherhealth care teams working in high-risk environments.7

Although clinical knowledge and experience wereseen as necessary, the application of both in a crisissituation was also identified as an important partof effectiveness. The RRT nurse was a leader anddecision maker in managing the crisis situation.Typically, the critical care nursing experience acquiredby nurses who work in ICUs contributes to the nurses’proficiency in recognizing and taking appropriateactions in crisis situations. Residents and internswho respond to an RRT event may or may not havethis experience. Crisis situations are complex anddynamic, and members of an RRT need to collabo-rate, make contributions according to their individ-ual abilities and experience, and work as a team.The importance of a team member’s ability to focuson and manage critical situations is a distinctive find-ing in our study and can be used to guide selection,training, coaching, and evaluation of response teams.

Teamwork behaviors occurred as individualmembers of an RRT coordinated actions and com-munication. Coordination centered on the commongoal of meeting the patient’s immediate needs.Open communication with purposeful dialoguewas identified as important for team effectiveness.Effective team members used their communicationskills to focus on the patient’s needs, coordinateinformation seeking, and obtain a clinical grasp ofthe critical situation at hand. To the study partici-pants, teamwork meant knowing one another andworking collaboratively with a shared purpose.Although familiarity was not expected, when present,it contributed to trust. Members of an RRT typicallyhave little opportunity to form as a team or to developrelationships because the urgency of the responsesituation usually takes precedence. The next call fora RRT might involve a team that, except for the RRTnurse, consists of different members. Thus, familiar-ity may be a more important dimension for effec-tiveness in these teams that must perform underconditions of uncertainty and urgency. Although therotational nature of the responders, who are differ-ent each shift, may preclude the development ofrelationships in situ, interprofessional team trainingamong members of an RRT can be an alternative wayto foster familiarity. Time and attention to multidis-ciplinary training that focuses on communication,collaboration, and a team orientation were recog-nized as necessary for effective performance of anRRT. Training needs identified included buildingrelational skills as a team by using simulation tofacilitate learning together and by practicing per-forming as a team in a nonurgent setting. Training

teamwork as a team in a nonurgent setting and saidit would “help build communication . . . cama-raderie between nursing and physicians and otherhealth staff. . . . I think simultaneous training [ofnurses and MDs] is best with sample cases and sim-ulation so that people could have a dialogue whenit’s not an actual critical situation.”

DiscussionResponse team effectiveness began with an

organizational culture in which innovation toimprove patient safety was valued and organiza-tional leaders were supported to adopt initiativeswith the potential to reduce adverse outcomes. Thesupportive culture contributed to the developmentof a response team. As a public, safety-net hospital,the study site’s mission is to serve a vulnerable pop-ulation of patients. This mission elicited a unifying

commitment to improvement andcontributed to the support evidentfor innovations in patient safety.Design and implementation of anRRT were the direct result of a per-vasive mission, organizationalleadership, and active support forchange. Administrative leaderswere committed to improvement,and a nurse and a physician acted

as coleaders of the RRT design team as clinicalchampions. Alignment of administrative and clini-cal leadership was a foundation that enabled inno-vation and advancement of safety practices.Qualifications for members of an RRT included spe-cialized clinical knowledge and experience. Nurseswho were preparing to respond as the RRT nurseparticipated in training that focused on clinical sce-narios and recognizing deterioration in a patient’sclinical condition.

The structure of an RRT contributed to thenurses’ effectiveness in detecting patients’ risks andresponding. Having dedicated nurses with criticalcare nursing experience interact with bedside nursesto assess risk strengthened surveillance, engenderedtrust, and promoted nurse-nurse synergistic collabo-ration. When an RRT was called to intervene, theteam process involved sharing leadership in theteam’s response to the situation, applying clinicalknowledge and experience, and managing the prior-ities and urgency of the patient’s needs.

The interviews clearly indicated that expertisewas perceived as key to an RRT’s effectiveness. Teammembers needed to be highly skilled, able to iden-tify potential problems, and have excellent assess-ment skills. The perceived importance of expertise is


A nurse and a physician led the team that

designed the rapidresponse team.




in teamwork was not provided as part of the train-ing for the RRT. This situation is not atypical, andmany teams in health care have not had training inteamwork. This trend is beginning to reverse withthe development and dissemination of a nationalinitiative to provide team training in health care set-tings by using TeamSTEPPS,50 a program availablefrom the Agency for Healthcare Research and Qual-ity and the Department of Defense.

ImplicationsEffective teamwork and communication are

associated with safe, high-quality care delivery.2,14

Communication is one of the required standardsadopted by the American Association of Critical-Care Nurses as a necessary component of healthywork environments.51 In this study, communicationbetween physicians and nurses was identified as keyto the effectiveness of an RRT. Good communica-tion was identified as critical to both the effective-ness of individual team members in responding toemergency situations and the effective functioningof the team. Responding to potential deteriorationin a patient’s clinical condition requires effectivecommunication and is therefore an important focusin evaluating effectiveness. The work carried out byan RRT nurse is often referred to as critical care out-reach, meaning that critical care practices are usedoutside the ICU. The actions of an RRT nurse aresimilar to those used by critical care nurses forpatients in urgent and life-threatening circum-stances. In this context, communication amongphysicians and nurses in critical care has been anarea of focus for more than 20 years.

In a landmark study published in 1986, Knauset al52 found that communication and collaborationbetween critical care nurses and physicians influ-enced mortality. Some would say that communica-tion and collaboration between these 2 groups ofhealth care providers have not yet been optimallyaddressed. In health care settings, in particular, teamsare formed, and individuals are expected to performin teams, but little development and training are pro-vided to teach individuals from different disciplinesabout how to perform together as a team. The find-ing that RRTs encounter communication as anobstacle is not surprising. Development of theseresponse teams is both an opportunity and a chal-lenge to clinicians to develop relationships, credibil-ity, and trust and to eliminate traditional hierarchiesamong physicians and nurses in decision makingand communications.48,53

Our interview data and observations of theRRTs indicated that the RRT nurses have individually

developed skill in good communication. The RRTnurses effectively communicated with physician teammembers without overtly usurping the physicians’authority and respectfully ensured safe care for thepatient. These nurses have adapted to meet a needon a case-by-case basis that supports the RRTs’ per-formance as a team. We should not, however, con-tinue to rely solely on the strengths that experiencedcritical care nurses contribute to multidisciplinaryteams. Rather, we must use interprofessional educa-tion that involves physicians and nurses learningtogether as the standard that supplements the indi-vidual skills of the professionals involved. A system-atic approach that includes practice and dialogue toadvance communication, achieve clarity of roles, gainan understanding of the authority and scope of prac-tice of nurses and physicians, and learn how to col-laborate in shared decision making is overdue.

Exploring what constitutes effective multidisci-plinary teams from the perspectives of the teams’members and from the points of view of the profes-sionals involved in actualizing the team is useful.Findings can provide a basis and a guide for evalua-tion, by using observation and/orqualitative inquiry, by individualsexternal to the team. These findingsraise awareness of the need for eval-uation of effective team functioninginternally as well. Communicationis essential to the performance ofmultidisciplinary teams. Determin-ing at regular intervals how well themembers of a team perceive com-munication is necessary. Hospitalsare complex health care environments where imme-diate feedback is critical for safe care even under thepressure of time constraints. For RRTs then, once theteams are operational, external and internal evalua-tion of effective team functioning is indicated. Theseteams operate in a natural setting; respond to callsepisodically; and are loosely coupled, with memberschanging frequently. The unpredictability of theevents that require an RRT can make planning obser-vation of the team difficult. However, evaluation viateam debriefing immediately after an intervention canbe highly informative and useful for performanceevaluation and team learning.

LimitationsOur study findings represent the development

and evolution of the RRT in a single health careorganization, but inclusion of study participantsfrom nursing, medicine, and administration andobservations of RRT calls in several different med-

It was evident fromthe interviews thatexpertise was perceived as keyto the team'seffectiveness.





focused on patients’ outcomes. Team members do nothave much opportunity to form relationships or toknow one another. In order to support the added valueof familiarity, additional efforts are needed to providetraining on teamwork by having team members learntogether as a team in simulated rapid response situa-tions, and debriefings after RRT episodes are indicated.Additional evaluation that includes each team member’sassessment of the team’s performance and observation ofthe team applying the knowledge and skills from train-ing to clinical practice in actual response situations isneeded. Evaluation of team functioning and what a teamneeds to function effectively, including qualities such asexpertise, behaviors such as communicating, and influ-ences of the environment in which the team functions,is an important element of team building, improvement,and effectiveness, particularly among teams that formand dissolve rapidly yet need to deliver coordinated carein every response the team makes. Research to measurethe performance of health care teams in relation to thestructure of the teams and teamwork and the influenceof structure and teamwork on outcomes is needed.Team-based care delivery is not an optional approachin the quest to achieve safe and reliable care for everypatient, every time—it is an imperative.

ACKNOWLEDGMENTSThis research was sponsored by the Association of Califor-nia Nurse Leaders and was funded by the Gordon andBetty Moore Foundation and the University of California,Los Angeles, School of Nursing.

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CNE Test Test ID A13223: Rapid Response Teams: Qualitative Analysis of Their EffectivenessLearning objectives: 1. Identify 5 categories that encompass team effectiveness. 2. Discuss the components of an effective rapid response team (RRT). 3. Describepotential barriers to implementation of an RRT.

Program evaluation Yes NoObjective 1 was met ❑ ❑Objective 2 was met ❑ ❑Objective 3 was met ❑ ❑Content was relevant to my nursing practice ❑ ❑My expectations were met ❑ ❑This method of CE is effective for this content ❑ ❑The level of difficulty of this test was:

❑ easy ❑medium ❑ difficultTo complete this program, it took me hours/minutes.

Test ID: A13223 Contact hours: 1.0; pharma 0.0 Form expires: May 1, 2016. Test Answers:Mark only one box for your answer to each question.

1. Which of the following is the def inition of a team?a. Two people who come together and act interdependentlyb. A group of people that have shared goals with separate roles, who carry out interdisciplinary tasks, and are able to adapt to changing situationsc. A group of people working on an activityd. Individuals who act independently

2. This study is which of the following?a. A phenomenological studyb. An ethnographic studyc. A case studyd. A descriptive qualitative study with a grounded theory method

3. The inclusion criteria for selection of an institution included which of thefollowing?a. Support of the RRT process, innovation with the organization to achieve safe care and improve patient safety, and staff ’s acknowledgement of the success of the RRTb. Informed consent obtained from patients and support from leadership c. It was a small, community, non-teaching hospitald. Support of the RRT process and a poor safety record with the need to improve patient safety

4. Hospital documents that were reviewed during data collection includedwhich of the following?a. RRT training manual, RRT log, RRT documentation template, and RRT physician ordersb. RRT training manual, RRT log, RRT documentation template, and description of the role of the RRTc. RRT training manual, RRT log, RRT documentation template, and description of the role of the respiratory therapistd. RRT training manual, RRT log, RRT documentation template, description of the role of the RT, and RRT physician orders

5. The study concluded that there are 5 categories that contribute to an effectiveRRT. These categories include which of the following?a. Organizational leadership support, surveillance, leadership, expertise, and familiarityb. Organizational culture, team structure, surveillance, expertise, and communicationc. Shared purpose, familiarity, defined roles, and surveillanced. Organizational culture, team structure, expertise, communication, and team work

6. Through the interview process, the participants in the study identif iedwhich of the following as important to RRT success?a. Communicationb. Team Workc. Expertised. Organizational support

7. The authors concluded that which of the following is the key to RRT effectiveness?a. Surveillance of at risk patients during roundingb. Use of critical thinkingc. Prior critical care experienced. Communication between the nurses and physicians

8. Limitations of this study include which of the following?a. Single health care system, the structure of RRTs varies in other institutions, lack of interviews with the respiratory therapistsb. Use of the health care system in a prior RRT study, lack of support from leadershipc. Providers who felt threatened by the implementation of the RRT, lack of interviews with the respiratory therapistsd. No limitations were identified

9. To improve functionality of the RRT, organizations should support teamtraining, simulation and debrief ings to add which of the following importantvalues to the RRT?a. Trainingb. Shared purposec. Familiarityd. Clinical knowledge

10. Two primary roles of the RRT nurse include which of the following?a. Surveillance of patients at risk and bringing critical thinking to the bedsideb. Collaboration and leadershipc. Responding to code blue calls and collaborationd. Surveillance and assisting with critical care transport

11. During RRT observations, which of the following were barriers to effectivecommunication?a. Lack of problem-focused report, inability to identify people’s roles, and lack of patient focus b. Disinterest on the part of the bedside nurse and lack of time to provide informationc. Use of jargon and unfamiliar termsd. Information overload and inattentiveness

12. Conf licts that may arise during implementation of an RRT may includewhich of the following?a. Lack of support from leadership and staff nursesb. Different goals of care among providers, fear of criticismc. Role confusion, sense of failure to identify/rescue prior to RRT initiation, feeling threatenedd. Lack of critical care expertise, role confusion, negative feedback during debriefing

For faster processing, takethis CNE test online atwww.ajcconline.org

(“CNE Articles in This Issue”)or mail this entire page to:AACN, 101 Columbia, Aliso Viejo, CA 92656.

Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%) Category: CERP C Test writer: Laura Dechant, APN, MSN, CCRN, CCNS

9. ❑a ❑b ❑c ❑d

8. ❑a ❑b ❑c ❑d

7. ❑a ❑b ❑c ❑d

6. ❑a ❑b ❑c ❑d

5. ❑a ❑b ❑c ❑d

4. ❑a ❑b ❑c ❑d

3. ❑a ❑b ❑c ❑d

2. ❑a ❑b ❑c ❑d

1. ❑a ❑b ❑c ❑d

10. ❑a ❑b ❑c ❑d

12. ❑a ❑b ❑c ❑d

11. ❑a ❑b ❑c ❑d

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Linda Searle Leach and Ann M. MayoRapid Response Teams: Qualitative Analysis of Their Effectiveness

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10.4037/ajcc2013990 198-210 22 2013;Am J Crit Care

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