Technical Summary: inproTeamED – Interprofessional Clinical Assessment in the Emergency Department

Problem Statement

In central emergency departments (EDs), the assessment and treatment of patients rely heavily on the interprofessional collaboration (IPC) between nurses and physicians. While the volume and complexity of cases are increasing, existing research often focuses on specific high-stress scenarios (e.g., trauma, resuscitation) or outcome-oriented triage systems (e.g., Manchester Triage System) rather than the day-to-day collaborative processes of clinical assessment. There is a need to understand the individual clinical reasoning (CR) processes of both professions, how these intersect at the social-interprofessional level, and how structural factors (such as digitalization and hierarchy) influence the quality of assessment and care. Specifically, the study seeks to explore the similarities and differences in how nurses and physicians approach clinical assessment and identify barriers and facilitators to effective IPC.

Methodology

This study employs a qualitative research design based on an interpretive paradigm, aiming to reconstruct the meanings, experiences, and decision-making processes of ED staff.

• Study Design: Semi-structured, face-to-face individual interviews.
• Participants: 13 permanently employed staff members from three central emergency departments at Klinikum Bielefeld gGmbH (Germany). The sample consisted of 10 nurses and 3 physicians.
  • Demographics: The average age was 49 years (median 52). The sample was predominantly female (10 females, 3 males) and experienced, with 9 participants having over 15 years of clinical experience and 6 having over 15 years of ED-specific experience.
  • Recruitment: Participants were recruited via department heads and team leaders. Inclusion criteria required permanent employment and assignment to the ED; exclusion criteria applied to temporary staff and medical assistants (MFA).
• Data Collection: Interviews were conducted between late 2024 and early 2025. A short questionnaire collected demographic data prior to the interviews.
• Analysis: Data were analyzed using structured qualitative content analysis based on Mayring's approach. The category system was developed deductively from the interview guide and iteratively expanded inductively. To ensure quality, independent coding by researchers with different professional backgrounds (medicine and nursing) was followed by consensus discussions (researcher triangulation). The analysis was performed using MAXQDA 24 software.
• Ethics: The study received approval from the ethics committee of the Westfalen-Lippe Medical Association. All participants provided written informed consent.

Key Contributions and Results

1. Individual Clinical Reasoning (CR) Processes

Both professions utilize elements of the Dual-Process Theory (System 1: intuitive/heuristic; System 2: analytical/deductive) in their initial assessments, though with distinct emphases:

• Shared Factors: Both groups prioritize unbiased assessment, vital signs, and diagnostic imaging. They rely on "overall clinical impressions" derived from facial expressions, posture, skin color, and alertness.
• Professional Differences:
  • Physicians: Emphasized the physical examination as a primary tool and engaged in more frequent, explicit reflection on their cognitive processes. They viewed intuition (System 1) as a process linking contextual factors with experiential knowledge.
  • Nurses: Focused more on clinical observation, patient flow management, and accelerating the process. They described their intuition more as an unreflected "gut feeling" (System 1) and relied heavily on clinical experience. While they use fixed algorithms (System 2, e.g., MTS), experienced nurses noted these are insufficient for holistic assessment.
• Role of Experience: Experience was identified as a critical prerequisite. Less experienced staff relied more on fixed structures (MTS, ABCDE algorithms), whereas experienced staff increasingly utilized intuition and independent assessment.

2. Interprofessional Collaboration (IPC)

IPC was generally perceived positively when fundamental principles of collaboration were met, but negatively when structural or interpersonal barriers arose.

• Positive Drivers: Successful collaboration was characterized by flat hierarchies, role flexibility (e.g., physicians performing nursing tasks in acute situations), mutual trust, and active involvement of nurses in decision-making. A "seamless collaboration" was reported within core teams with high familiarity.
• Negative Drivers:
  • Individual/Interpersonal: Conflicts with specific individuals, unprofessional behavior, and perceived lack of respect.
  • Structural: Delays caused by the unavailability of on-call physicians, particularly in rural settings or smaller teams. Legal uncertainties regarding telephone orders and the inability to prove communication attempts were cited as significant stressors.
  • Regional Differences: In larger EDs, lack of physician presence was interpreted as a lack of seriousness; in smaller teams, it was attributed to high workloads.

3. Communication and Digitalization

• Communication: Technical jargon barriers were rare within the core team. Communication was described as "firm but friendly." Nurses sometimes sought feedback on their assessments, while physicians focused on didactic guidance. Barriers were more common with external medical personnel.
• Digitalization: Digital documentation was viewed as indispensable for security, traceability, and information flow. However, poor usability (e.g., time-consuming data entry) was reported to increase workload and reduce time for direct patient care. Generational differences were noted, with older staff (51+) expressing more difficulty adapting to new digital tools compared to younger colleagues.

4. Suggestions for Improvement

Participants identified needs at three levels:

• Personal: Stress resilience, flexibility, and communication skills.
• Social/Team: Structured practical guidance for new staff, interprofessional training (simulations, trauma room training), and fostering familiarity.
• Structural: Improved staffing ratios, parallel medical/nursing assessments, spatial changes, and system improvements for digital tools.

Significance and Claims

The paper claims to provide insights into the individual CR processes as perceived by nurses, noting that the medical perspective in the sample was limited. The study demonstrates that:

1. Complementary Approaches: Physicians and nurses complement each other in the ED; physicians tend to reflect more on cognitive processes, while nurses emphasize holistic observation and flow.
2. Experience is Key: Clinical experience is a fundamental prerequisite for effective assessment and the development of intuitive reasoning (System 1).
3. IPC Conditions: Successful IPC is contingent upon adhering to principles of equal footing, flat hierarchies, and mutual respect. When these are violated, or when structural issues (like physician availability) arise, collaboration suffers.
4. Digitalization: While digital tools are essential, their implementation must address usability to prevent increased strain.

The authors modestly conclude that while the findings offer valuable perspectives on the interprofessional dynamics in EDs, the results are primarily reflective of the nursing perspective due to the sample composition. They suggest that future research should expand to include more medical staff and utilize quantitative tools (e.g., JSATPNC) to validate these findings across broader settings. The study underscores that effective interprofessional shared decision-making requires not only continuing education but also structural adjustments to support collaborative models.