Background Medical Emergency Teams (MET)/rapid response are replacing Cardiac Arrest teams in acute hospitals. There is a lack of knowledge about how Critical Care Nurses (CCNs), rostered on MET construct their responsibilities/roles.
Objective Assess MET nurse activities at different hospitals.
Methods The authors used visual ethnography; selecting Systemic Functional Grammar as our methodological framework. The Generic Systemic Potential was used to guide the coding of visual and inferential meaning of the activities of MET nurses. CCNs coded over 6 h of videoed MET calls, sampled across three hospitals, Sydney, Australia.
Results The first layer of coding contained 1042 discreet tasks. They were sorted into 15 Areas of Practice (AOPs) and then allocated to aspects of performance (psychomotor and cognitive). The AOPs ‘Assisting with Procedure’ through to ‘Monitoring Vital Signs’ reflect psychomotor skills which account for almost half (48%) of the AOPs at site 1 and three-quarters at sites 2 (70%) and 3 (78%). Eight generic responsibilities/roles were identified. ‘Ongoing Assessment,’ ‘Re-evaluating Risk’ and ‘Prioritising Interventions’ were the most prominent. The patterns differed by hospital: ‘Re-evaluating Risk’ was prominent for sites 1 and 2 but less so for site 3.
Conclusion ‘Ongoing Assessment’ and ‘Re-evaluating Risk’ occupied almost half of the MET nurses time, whereas ‘Establishing Patient Acuity, the key activity in CA teams, occupied only 4%. These findings provide evidence of the roles of CCNs in the MET and suggest that education and training of MET nurses should support these roles.
- Resuscitation practice
- medical emergency team
- critical care nurses
- expert performance
- visual semiotics
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Medical Emergency Teams (MET) and Outreach teams are replacing Cardiac Arrest (CA) teams in acute hospitals.1–6 The overall aim is the early identification and intervention of at-risk patients.1–6 The MET is staffed by critical care nurses (CCNs) and intensivists.1 7 8 It may be described as an itinerant team of ICU clinicians providing care outside the walls of ICUs.9 The reasons for MET calls are many and varied, and range from relatively minor to life-threatening situations.6–10 Historically, research into resuscitation and trauma has focused on correct implementation of protocols. Little attention has been given to aspects of the clinical performance of resuscitation practitioners, particularly CCNs and how they use their experiential knowledge within MET.10 11
The ‘Novice to Expert’ concept suggests that postgraduate nurses have two different ways of knowing: theoretical and experiential.11 The latter was the topic for our study, based on the concept that a MET call is an exemplar of the need to apply experiential knowledge in response to the contingent nature of nursing practice.11
In 1984, Benner introduced the concept: ‘the trademarks of expert practice is its contingent nature; action is taken depending on the particular rather than the typical situation at hand.’11 She contended that: ‘we cannot afford to ignore knowledge gained from clinical experience by viewing it only from simplified models or from idealised, decontextualised views of practice.’11 She identified a need to understand ‘how the context and meanings inherent in clinical situations influence the performance of the expert.’11 A few studies have applied Benner's concept to explore the performance of specialist nurses.12
We aimed to explore knowledge and meanings in the performance of MET nurses, based on the visual and inferential meaning of observed clinical practice.
Systemic Functional Grammar (SFL) was the framework for our study, a social semiotic approach which views all behaviour as potentially meaningful.13 Within SFL, all behaviour and the environment surrounding it can be examined from the perspective of how it creates meaning.13 Instances which share a similar function within the culture, for example MET calls, are likely to share a similar structure, termed the Generic Structure Potential (GSP).14 Research suggests that it is possible to state a GSP.14 A GSP does not exclude variation, but this variation will relate in a specific way to the function of that context in the culture. Hence, it is a useful tool for gaining an understanding of the roles/responsibilities of participants (MET nurses) in a context (MET calls).
Purposive sampling was used to capture 26 MET calls, sampled across a Tertiary Referral Centre (site 1), a Major Metropolitan Hospital (site 2) and a General Metropolitan hospital (site 3) in a Sydney South West Area Health Service, between June and December 2006. MET calls were filmed over 8 weeks, covering all shifts, including weekends, to allow for temporal variation in the structure of care. One camera focussed on the MET nurse during the MET call.
The videos were analysed by two researchers and 18 CCNs with an average experience of 11 years in Critical Care and 8 years in the MET system. Analysis was based on Benner's premise that such professional groups ‘share a large stock of intersubjective meanings that all participants understand on an explicit level.’11 This provided access to the experiential knowledge of MET nurses.11 This reflexive approach to coding was a key analytical strategy to ensure relevance and credibility of our findings.
Visual and inferential meaninga of the actions of the MET nurses were annotated separately for each video. Differences in counts and proportions were used to summarise and describe the data. Differences do not represent statistical differences but profile the differences in the patterns of clinical practice, in response to the context of each MET call.
Data were coded in three orders of abstraction based on GSP.14 The first order was at the more concrete level of narrow task-orientated assessment. The second and third orders of abstraction make explicit the pressures that model the choices MET nurses make in the context of MET calls, and local culture. Context means the myriad of factors that are in operation during a MET call and may cause the MET nurse to act in a particular way as the MET call unfolds. Participants only coding MET calls videoed in their hospital ensured that knowledge of cultural insiders are brought to the analysis. Data management and analysis (orders of abstraction) are described in appendix 1.
Videos totalled 10 for site 1, 6 for site 2 and 4 for site 3, representing a total recording time of 6 h and 41 min over an 8-week period. The number of videos reflected the relative frequency of MET calls for each hospital.
First Order of abstraction (tasks)
The number of tasks were: 526 for site 1, 293 for site 2 and 223 for site 3. The typicality and the intensity of some of the tasks were different for each of the three hospitals. The number of tasks also reflected the number of METs per hospital. Overseeing MET was the most prominent task for site 1; documenting was the most prominent for site 2; and cardiac monitoring was the most prominent for site 3.
Second Order of abstraction
Fifteen Areas of Practice (AOPs) were established as a result of sorting all tasks from Stage 1 analysis (appendix 2). Data were arranged into three subsets: one predominantly based on psychomotor skills, one based on cognitive skills and one where neither appeared to dominate.15 16
The subset ‘Assisting with Procedure’ through to ‘Monitoring Vital Signs (VS)’ constitutes psychomotor-based skills. They accounted for half of the AOPs at site 1 (48%) and three-quarters at sites 2 (70%) and 3 (78%). Most of the MET nurses' time was spent on ‘Gathering Information’ (cognitive and psychomotor) at site 1; for site 2 it was ‘Monitoring VS’ (psychomotor); and for site 3 it was ‘Performing a Procedure’ (psychomotor).
3rd Order of abstraction (responsibilities/roles)
Eight generic responsibilities/roles were identified (figure 1). The eight roles all MET nurses employed were ‘Ongoing Assessment’ (27%), ‘Re-evaluating Risk’ (19%), ‘Prioritising Interventions’ (17%), ‘Documentation’ (9%), ‘Participating in Management Plan’ (5%), ‘Establish Patient Acuity/Risk’ (4%) and ‘Recognise the Expertise of Home Team’ (2%). Overall ‘Ongoing Assessment,’ ‘Re-evaluating Risk’ and ‘Prioritising Interventions’ were the most prominent responsibilities/roles. The way MET nurses sequenced these responsibilities/roles varied with each of the MET calls, moderated by the specific context of an MET call.
The pattern differed by hospital: the role ‘Re-evaluating Risk’ was prominent for site 1 and site 2 but far less so for site 3. For ‘Prioritising Interventions,’ this pattern was almost reversed: this role was prominent for site 2 and site 3 but much less so for site 1 (figure 1).
‘Performing a Procedure’ was the AOP most commonly used by all hospitals for the role ‘Prioritising Interventions.’ ‘Providing basic care’ was most common for site 1. For the role ‘Ongoing Assessment,’ MET nurses from site 3 most commonly used ‘Monitoring VS,’ whereas MET nurses from site 1 utilised ‘Gathering Information.’ ‘Gathering information’ and ‘Monitoring VS’ were used most often at all three hospitals for the role ‘Re-evaluating risk’ (figure 2).
MET nurses allocated half of their time (46%) to two of their eight roles, ‘Ongoing Assessment’ (27%) and ‘Re-evaluating Risk’ (19%), and only 4% to ‘Establishing Acuity/Risk.’ The latter role constitutes core activity for conventional Cardiac Arrest teams. Thus, our findings suggest that the context of MET calls has reshaped resuscitation practice for MET nurses; they provide evidence for the concept proposed by Dr Benner: ‘the context and meanings inherent in clinical situations influence the performance of the expert.’11
The patterns of the eight roles varied by hospital; ‘Re-evaluating Risk’ was more prominent for site 1 (figure 1). This finding is consistent with the concept of the GSP: role variations at the hospital level relate in a specific way to the function of MET calls in the context of the culture of each hospital.14
Layering the annotations in three orders of abstraction meant that analysis moved from the parts back to the whole.13 We were able to explore in detail the expert performance embedded in the clinical practice of MET nurses. To describe AOP, we used the Domains of learning proposed by Bloom.15 16 We created three categories based on the psychomotor and cognitive aspects of performance (appendix 2). There was a need to understand technical skills and problem-solving strategies, rather than compile lists of nursing tasks.13 14 For the ‘Re-evaluating Risk’ role, the AOP ‘Gathering Information,’ a blend of psychomotor and cognitive practice, was most prominent. Another important AOP within this role, ‘Monitoring VS,’ was almost exclusively psychomotor based. Thus, the details of the second layer of analysis indicate that while applying a range of routine skills, for example, monitoring VS, the MET nurses engaged in high-level clinical problem solving as defined in the Competency Standards for specialist CCNs.12
In their role, ‘Re-evaluating Risk,’ MET nurses evaluated and responded to changing situations. This involves not only stabilising the vital signs of patients, but an assessment of the fit between levels of care and the needs of patients. Skills associated with oxygen therapy, 12-lead ECG, intravenous fluid administration, critical thinking and decision-making are centre stage in monitoring at-risk patients.17 18
The pattern of AOPs within the ‘Re-evaluating Risk’ role was different for each hospital, reflecting the impact of the context of culture on performance. The most striking difference was for the AOP, ‘Receiving/relaying information,’ a cognitively based skill: for site 1 the proportion was 15%, for site 2 it was 1%, and for site 3 it was not applied at all. The other prominent AOP, ‘Gathering information,’ a combined psychomotor and cognitive AOP, also varied by hospital: it constituted almost half of the role at site 2 and only 19% at site 3. When observing the context of MET calls at site 3, it was apparent that ‘Gathering information’ was predominantly undertaken by the MET doctor. This phenomenon as well as the nature of the MET calls might explain the need for MET nurses to engage in more psychomotor-based skills at site 3. It is important to emphasise that site 3 MET nurses constructed a response tailored to their context. Their psychomotor-based response did not diminish their capacity for critical thinking and decision-making in managing patient risk.17 18
We selected SFL and GSP13 14 as our analytical guide; and co-opted the CCNs as researchers. This framework provided new knowledge about how CCNs adapt their performance during MET calls. It provides evidence that the MET system has redefined resuscitation practice compared with CA teams.
The impact of hospital culture on clinical performance during an MET response was an important finding. It highlights the importance of understanding local culture when developing education and professional support for MET nurses. Proficiency in advanced resuscitation skills was not sufficient to sustain the performance of MET nurses in our study, as they responded to the clinical demands presented by a broad range of clinical problems. As expert clinicians, they were influenced by the context and meanings inherent in three different hospital cultures.13 14 18 This was borne out by the commonality and the differences displayed in their construction of responsibilities/roles. Overseeing MET being the most prominent task for MET nurses in site 1 reflected the supervisory role these nurses play because of the availability of resources to support MET in comparison with other sites. It was only MET nurses at site 1 who took on an ‘External role’ (ie, answering phone calls about beds during MET); they also had the opportunity to ‘Learn from home teams’ (ie, cardiologist troubleshooting a pacemaker problem) in the specialised environment of site 1. Hence, our study provides information about how MET nurses contextualise expert performance.11 18
This study provides new knowledge on the role of MET nurses. ‘Ongoing Assessment’ and ‘Re-evaluating Risk’ occupied almost half of the MET nurses time, whereas ‘Establishing Patient Acuity,’ the key activity in CA teams occupied only 4%. Education and training of MET nurses should support these roles.
We would like to thank the Clinical Analysis Group: K Armstrong, V Brillante, K Brennan, C Chan, M Clare, L Curley, S Hedges, J Murphy, M Nicholson, S Parker, SA Shunker, J Stevenson, N Twadell, D Sanchez, V Sutevski, M Quach and M Whelan. We would also like to thank the critical care nurses, ward staff, patients and the Simpson Centre staff, who in one way or the other supported this video-based study, and L Whyte, who assisted in the completion of this manuscript.
Appendix 1 Data management and analysis
Videotapes were converted into a format compatible with the ELAN software19 used for coding and managing the data. The measures applied to safeguard privacy and confidentiality have been published elsewhere.20
The study was approved by the local Human Research Ethics Committee with all participants providing written, informed consent.
Orders of abstraction
For each video, the smallest units of meaning of the actions of the Medical Emergency Team (MET) nurse (‘measure BP’) were annotated separately and then cross-referenced between two researchers. Thereafter, all annotating and analysis was group-based. In the second round of coding, participants sorted the tasks annotated during Stage 1 into Areas of Practice.15 16 This represented a more abstract level of coding the data, where situational and clinical aspects were incorporated. At the third round, changes (tropes) in the responsibilities/roles of the MET nurse were identified as the MET call unfolded. This stage reflects the highest order of abstraction, the context of culture of MET, and includes information about the expert practice embedded in the resuscitation practice of MET nurses. Layering the annotations in three orders of abstraction created a framework whereby analysis moved from the parts back to the whole.
Appendix 2 Areas of practice
|Areas of practice (second-order analysis)||Tasks|
|Psychomotor skills||Monitoring vital signs||Physically check vital signs (eg, blood pressure, pulse, respiration, temperature and oxygen saturation; set up monitoring equipment and report results), request and relay vital signs|
|Performing a procedure||Perform procedures to stabilise the patient (eg, performing 12-lead ECG, blood glucose level and oxygen therapy)|
|Troubleshooting||Fix malfunctioning equipment (eg, alarms and intravenous access)|
|Assisting with procedure||Assist with any procedure (eg, blood collection, 12-lead ECG, fluid administration)|
|Organising equipment||Locate, set up and disconnect equipment|
|Providing basic care||Observe Occupational Health and Safety Guidelines, protect patient privacy, reassurance and housekeeping|
|Cognitive Skills||Overseeing MET||Observing the MET scene, without verbalising but assessing and evaluating the process|
|Receiving/relaying information||Act as a conduit for relevant information relevant to the MET process (eg, patient history, reason for MET call)|
|Education/feedback||Imparting knowledge to another individual such as staff or patient|
|Handover||Relay information to establish continuity of care|
|Cognitive and Psychomotor Skills||Gathering information other than vital signs||Glean information other than vital signs, reviewing notes and procure laboratory results|
|Facilitating care||Oversee the completion of tasks (eg, delegate blood glucose level (BGL), coordinate administration of medication and identify the need for procedures)|
|Terminating MET||Packing up the MET trolley with the intent to leave or verbalising the need to close MET|
MET, Medical Emergency Team.
Competing interests None.
Patient consent Obtained.
Ethics approval Ethics approval was provided by the Sydney South West Area Health Services—Ethics & Research Office, Liverpool.
Provenance and peer review Not commissioned; externally peer reviewed.
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