Cognitive Psychology response Essay Example | Topics and Well Written Essays - 750 words

Cognitive Psychology response - Essay Example The memory can also be triggered at anytime. Recovered memories are memories, which have been perceived to be irretrievable for a certain amount of time. False memories are when a person has recollection of a memory that never occurred. Research supports repressed memories, except there is debate whether this only occurs in trauma cases. There have also been cases in hypnotherapy where false memories have been implanted into a person’s memory, however there is no scientific evidence to support this. 2)Explain in detail the Atkinson-Shiffrin model of memory. It is sometimes referred to as the multimode of memory. It consists of sensory memory, short term memory, and long term memory. Sensory memory can only be held for a few seconds. If processed, it moves to short term memory where it lasts for approximately one minute and through rehearsal can be converted to long term memory which lasts indefinitely. 3)Define the term "reasoning" and explain the two basic forms of reasoning, giving examples for each. Reasoning is by process of thinking, an idea can form from another idea. Cognitive- instrumental reasoning involves the basis of the scientific method in that through observation, we are able to reason correlations and form hypotheses. Moral-practical reasoning is where you take into account the moral implications of making a decision based on faith, values system, culture, etc. 4)Describe the effect of learning to speak two languages on the process of language development.   Include any age-related differences that are discussed in the text.  Ã‚   Chomsky called this the language acquisition device in that at younger ages, children are much more cognitively developing than older children. They are constantly assimilating everything from their environment and integrating it into their memory. The idea behind the syntax and grammar of language requires multiple cognitive patterns and memory storage. Thus, children that are learning multiple languages ar e forming new connections and using more parts of their brain, which can allow them to succeed in other areas. 5)What would be the pros and cons to the idea of administering intelligence tests to all students? The pros to giving intelligence tests to students are that it allows schools to see how they are teaching and whether the teaching is effective. It also allows for standardization, meaning that students are put into classes which allow them to learn on a level of development that they are at. The cons to intelligence tests is that it locks students into an idea of what level of intelligence they are at. This can have serious consequences not only at the academic level, but also with self-esteem and interpersonal relations. 6)Based on memory research describe and give examples of at least four of the memory concepts a person could utilize to become a better student.   Repetition- the least effective, but multiple rehersal can help assimilation. Categorization- otherwise done with chunking, it allows students to store multiple pieces of information together Association- by making assocations with the knowledge and memory, it increases the ability to retrieve the information (most effective) Elaboration- by elaborating more on the topic, you learn more about the topic and

Auditing Essay Example | Topics and Well Written Essays - 2000 words - 4

Auditing - Essay Example Audit risk refers to anything that will prevent ABC Chartered Accountants from giving a correct and an appropriate audit report about Zebra. Inherent risk involves the risk that the operations of Zebra within the period had issues that could lead to material misstatements or errors (Collier and Agyei-Ampomah, 2010). This will include the risks that staff members and managers in Zebra can conduct certain fraudulent or wrong activities in course of the operation of the company. The obvious inherent risk involves the pressures and changes that occurred in the period. The obvious increase in the credit period which gives external entities access to funds meant for Zebra and this causes an extended lock up of capital which could lead to the significant defaults and losses to the company. There is also the risk of staff members overstating their earnings and their sales in order to gain the commissions that have been offered. Finally, the pressure to join the Australian Stock Market provides the risk for Zebra staff members to overstate the asset position in order to attain a favourable view before various investors and the Au stralian public. Control risks involve the possibility that the controls put in place by Zebras management and directors will be overridden in a way that could lead to fraud or errors in the financial statements (Pickett, 2010). This involve the risks of the EFTOS system being abused by some parties in the company to lead to fraud and error. Secondly, the risk of people overstating their sales and indulging in unethical practices plays a significant role in overriding the systems. Additionally, the management of Zebra could override the systems if they all indulge in groupthink and they all second the need to get listed to expand the firm. This could lead to major problems and issues that can involve the complete disregard for internal controls. Detection risks is the possibility of ABCs

Surveys in Measuring Flexible Employment in the UK Essay

Surveys in Measuring Flexible Employment in the UK - Essay Example A broad definition of 'atypical' employment is that adopted by Delsen (1991), who describes it as deviating 'from full time open ended work employment: part time work, seasonal work'. In the US the most common term which largely overlaps what is referred to in Europe as flexible working patterns is 'contingent work' (Freedman, 1986). ( H Harris, C Brewster and PSparrow,2003 pg 101) Although some consultants have tried to foster the term 'complementary working', Polivk and Nardone (1989) define contingent employment as 'any arrangement that differs from full time, permanent, wage and salary employment'. Morishima and Feuille (2000) noting that contingent employment can include a variety of workers The common themes that unite the individuals in these diverse categories are that they receive few or no fringe benefits, they have little or no expectation of long-term employment with the firm on whose premises they work at any given time, and they occupy a secondary position to the regular, full-time employees in the firm's status hierarchy. They conclude that although an accurate account of the situation in the USA and Japan, within the European contest such distinctions do not hold true. The complex aspects of flexible working practices render varying effects and implications. Part time work for example will apply to any work hours short of the normal working week for each country which vary across the globe. For instance in France and Belgium, part time work is defined as four-fifths or less of the collectively agreed working time; in the Netherlands and USA as less than 35 hours per week; in the UK as less than 30 hours, with lower thrash holds in relation to social security contributions. Elsewhere, the norm is concentrated around 25-30 hours per week (Bolle, 1997 and Brewster et al, 1996). THE FLEXIBLE FIRM Source: as cited in Keizer (2007). Various scholars have had their significant contributions to the entirety of the Flexibility discipline. Nonetheless John Atkinson stands out for his 'The Flexible Firm" model. Whilst at the institute of man power studies John Atkinson and his colleagues propounded the much quoted model depicting the divisions, between 'core and peripheral' work forces. In this model the core workers are full time permanent career employees who have won security by virtue of committing to functional flexibility in the short term and long term basis. The organisational value of such is encapsulated in the terms and conditions that bind them whilst their remuneration is largely influenced by their achievements including those of t the team and the organisation. (John Stredwick & Steve Ellis, Flexible Working Practices techniques and innovations, pg 11 & 12) The first peripheral group has less job security and access to career opportunity. And their jobs are plug in ones, not skill specific to the firm. Organization looks to the market place to fill the jobs, many of which are filled by the women, and numerical flexibility is achieved by the normal wastage which is fairly high. .(John Stredwick & Steve Ellis ,Flexible Working Practices techniques and innovations, pg 11 & 12) The second peripheral is an extension of the first, with much part time working, shift working, zero hour and short term contracts which maximize flexibility. Such terms and conditi

Auditing Essay Example | Topics and Well Written Essays - 2000 words - 4

Auditing - Essay Example Audit risk refers to anything that will prevent ABC Chartered Accountants from giving a correct and an appropriate audit report about Zebra. Inherent risk involves the risk that the operations of Zebra within the period had issues that could lead to material misstatements or errors (Collier and Agyei-Ampomah, 2010). This will include the risks that staff members and managers in Zebra can conduct certain fraudulent or wrong activities in course of the operation of the company. The obvious inherent risk involves the pressures and changes that occurred in the period. The obvious increase in the credit period which gives external entities access to funds meant for Zebra and this causes an extended lock up of capital which could lead to the significant defaults and losses to the company. There is also the risk of staff members overstating their earnings and their sales in order to gain the commissions that have been offered. Finally, the pressure to join the Australian Stock Market provides the risk for Zebra staff members to overstate the asset position in order to attain a favourable view before various investors and the Au stralian public. Control risks involve the possibility that the controls put in place by Zebras management and directors will be overridden in a way that could lead to fraud or errors in the financial statements (Pickett, 2010). This involve the risks of the EFTOS system being abused by some parties in the company to lead to fraud and error. Secondly, the risk of people overstating their sales and indulging in unethical practices plays a significant role in overriding the systems. Additionally, the management of Zebra could override the systems if they all indulge in groupthink and they all second the need to get listed to expand the firm. This could lead to major problems and issues that can involve the complete disregard for internal controls. Detection risks is the possibility of ABCs

Personal Case Study Paper Example | Topics and Well Written Essays - 1250 words

Personal Paper - Case Study Example Role conflict can come in various forms. Role conflict usually comes in the form of status, role, and expectation. There are a number of academic researchers that have been carried out with regard to role conflict. This paper aims at discussing how academic research relates to role conflict. There is always a variance in opinions when it comes to how role conflicts should be handled. However, what is certain is that the manner in which you manage role conflict determines how it will affect your organization. Regardless of the roles played or the individuals involved in a conflict both sides are always negatively affected by the conflict. Berko, Aitken & Wolvin asserts that when interdependent individuals or groups happen to have views, opinions, values, and goals that are conflicting it will be hard for them to work for a common course (Berko, Aitken & Wolvin, 2010). People who ignore role conflicts have a higher possibility of failing as compared to those who acknowledge their existence and work towards solving them. To make sure that role conflicts are put under control roles of the various individuals and groups that are interdependent should be defined. This will help everyone understand the boundaries of their roles and the importance of their role to the common purpose. When choosing or allocating roles you should make sure that people or groups are given the roles that they are best in. This will be in the bid of making sure that everyone is comfortable with the roles that they are supposed to play (Settles, Sellers & Damas Jr, 2002). This will mean that by the end of the day everyone would have played their roles and since the common course is dependent on the individual roles the common course will be achieved. However, Beaucham and bray asserts that letting people and groups play the roles that they are best in will reduce the possibility of there being complaints from the other individuals or groups involved in the course (Beauchamp &

Reimbursement and Pay-for-Performance Essay Example for Free

Reimbursement and Pay-for-Performance Essay Introduction As we come into the 21st Century, we find Healthcare is at a crisis level. Every agency is working on healthcare reform from policymakers to the public and private sector, as well as federally funded Medicare and Medicaid. The business of Medicine is greatly influenced by the government (federal, state and local levels) and private health sections that initiate policies. Pay for Performance is a reimbursement method where physicians and hospitals can receive a higher reimbursement for duplicate services based on the fact that they deliver better quality care with better results and outcomes. This payment reform offers initiates intended to improve efficiency, value, and quality of health care (Hood, 2007). If all doctors receive the same dollar amount as a doctor with poor outcomes, then the doctor with great outcomes should receive a little more and there will be patients that do not mind paying a higher deductible for better medical services (Mayes, 2006). Definition for Pay for performance Kimmel (2005), Pay for performance is a payment approach used in healthcare that is based on clinical information-driven reform. The fundamental concept is to tie payment to how well providers adhere to practice standards. The practice standards are evidence-based and tied to clinical outcomes. The primary areas of focus are preventive care delivery and disease management for chronic illnesses†. Effects on Reimbursement Pay for performance (P4P) is literally a group of performance indicators that are coupled with an incentive. The performance indicators supports the performance aspect of P4P while the incentive indicator is the pay component. Measuring patient outcomes and understanding the variances that  they have, has in part lead to the increasing rise in how pay for performance reimbursement is looked at. This style of reimbursement allows health plans and employers to pay increasing reimbursements to medical providers that have the better outcomes, give average outcome medical providers a chance to improve, and pay those medical providers with the lowest outcomes the least amount of money or not pay them at all (Cromwell, Trisolini, Pope, Mitchell, Greenwald. 2011). In order to have a pay for performance system in place, you must decide what domains or areas you wish to track, measure, and reward. Some areas in this domain are clinical process, quality and patient safety, access to and availability of care, cost efficiency or cost of care, cost-effectiveness, administrative efficiency and compliance, adoption of information technology, and reporting of performance indicators. These can be set up as a single performance tracker or a multi-domain performance tracker and the measure needed for improvement, importance, and cost. Performance indicators should be valid, reliable, and informative (Cromwell, Trisolini, Pope, Mitchell, Greenwald. 2011). The Incentive Schemes reward the performance measures, and is another important part of a pay for performance system. Funding proves to be another important part of this type of a reimbursement system. Types of funding include redistributing existing payments where additional funds will not have to be made and the quality of service is already high; however, medical providers with a lower quality of service will receive lower reimburse ments. Generated Savings and New Money are other sources of funding for performance measures. Generated savings claim that an increased quality of service will generate savings, although there are others who feel that new money should be used to fund the performance system. (Cromwell, Trisolini, Pope, Mitchell, Greenwald. 2011). Impact of System Cost Reductions on the Quality and Efficiency of Health Care The Medicare Physicians Group Practice (PGP) was the first physician pay for performance model used by the federal government. The PGP believes that higher quality and better cost efficiency could be achieved by managing and coordinating patient care and by engaging in wider choices of care management that are able to improve cost efficiency and quality of health care. Interventions include; chronic disease management, high risk and higher cost care management, transitional care management, end-of-life and palliative care programs. If there were a more  successful payment and delivery method to increase the value of health care and improve quality of care, the cost would grow at a slower pace. The American people would be more likely to purchase health insurance coverage that is affordable and more valuable. (Kautter, Pope, Trisolini, 2007). More progress toward effective delivery and system reform is one of the key elements to achieving the goals to push expanded coverage. Information technology is one of these key elements and a major part of pay for performance system. Information systems uses electronic medical records and patient registries have been created to improve the efficiency and quality of health care delivery. These type of initiatives that are being tested to see if cost savings are generated by reducing avoidable hospital stays, cutting down on readmissions and emergency room visits, while simultaneously improving quality of care (Kautter, Pope, Trisolini, 2007). Effect of Pay for performance on Health Care Providers and Their Customers Meredith B. Rosenthal states, Pay for performance will not replace the existing payment structure in either system, but it does allow payors to take into account a set of quality indicators, in addition to volume of service (as fee-for-service does now) or the number of covered lives (in the case of capitation). In this view, pay for performance can be viewed as a mechanism to correct some of the distortionary incentives that already exist in the reimbursement system. Physicians in the United States are paid on a fee-for-service basis. This encourages high volumes of services, where there is no regard to the value of services in regards to a patient. When services are reimbursed more generously than others it allows the payment system to influence additional medical services with a heavy emphasis on procedure-based care. Since the physicians pay is not attached to medical services provided, there is really no direct incentive to provide any services (How Will Paying for Performance Affect Patient Care?. (2006, March). Virtual Mentor, 8(3), 162-165). Effects of Pay for performance on the Future of Health Care Goldberg lists three points regarding the most significant implications of the movement toward paying for quality outcomes. These are that the quality and value become real parts of contractual reimbursement, the differences based on quality outcomes will be more evident grouped with provider tiers,  and quality metrics evolve to outcome-based and chronic disease management (Goldberg 2006). P4P is an incentive-based reimbursement system that rewards the best players. This pay for performance system is currently active in health systems, managed care settings, and private and group physician’s practices. P4P is likely to impact the entire health care environment and will provide yet another opportunity for pharmacy to become an active role player and leader with improving quality and efficient health care. The focus is not on value but on quality and cost. Pay for performance is not a new program, but in the age of informed choice, evidence based medicine, and patient safety, it can become the solution to our current health care dilemma (Pay for performance (P4P): Evaluating Current and Future Implications). Conclusion These pay for performance systems and programs will lead expansion across the United States health care industry in the near future. With the implementation of the Affordable Care Act, there has been a great amount of provision made to encourage continued improvement with quality of care. Accountable Care Organizations (ACOs) are groups of providers that agree to coordinate care and to be held accountable for the quality and cost of the services they provide (James, 2012). There needs to be a consensus as to how much of an incentive will have to be given in order to affect the needed change and how should these incentives be paid out monthly, quarterly, or yearly; and how can these improvements be sustained over time. Continued experimentation with the pay for performance model should begin to incorporate monitoring and evaluation in identifying design elements that will also affect outcomes in a positive way. Variations in health care markets should be evaluated and include comparison groups to isolate pay for performance from other types of factors. Pay for performance has some great attributes to it and could definitely be the beginning to improvements in quality of service. If physicians are receiving patients and referrals based on their ability to provide quality of service with reduced readmissions and more satisfied consumers, then the care they take in providing services to patients from admission to discharge will create positive change. References Cromwell, J., Trisolini, M. G., Pope, G. C., Mitchell, J. B., and Greenwald, L. M., Eds. (2011). Pay for Performance in Health Care: Methods and Approaches. RTI Press publication No. BK-0002-1103. Research Triangle Park, NC: RTI Press. Retrieved June 15, 2014, from http://www.rti.org/rtipress Goldberg, L. (2006). Paying for performance a call for quality health care. Deloitte Center for Health Solutions. Retrieved from http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/us_chs_p4p_032806%281%29.pdf Hood, R. (2007). Pay-for-Performance-Financial Health Disparities and the Impact on Healthcare Disparities. Journal of the National Medical Association, 99, 1-6. James, J. (2012). Pay-for-Performance. New payment systems reward doctors and hospitals for improving the quality of care, but studies to date show mixed results.. Health Policy Brief, 1-6, Retrieved June 15, 2014, from http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=78. Kautter, J., Pope, G., Trisolini, M. (2007, Fall). Medicare physician group practice demonstration design: quality and efficiency pay for performance. Health Care Financing Review, 29(1), 15-29. Retrieved June 15, 2014, from http://www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/downloads/PGP_D emo_Design.pdf Kimmel, K. (2005). Pay for Performance: An Economic Imperative for Clinical Information Systems. Retrieved June 15, 2014, from http://www.himss.org/content/files/PayForPerformance.pdf Mayes, R. (2006). The Origins of and Economic Momentum Behind Pay for Performance Reimbursement. Health Law Review, 15, 17-22. Pay for performance (P4P): Evaluating Current and Future Implications. Retrieved June 15, 2014, from https://www.ashp.org/DocLibrary/Policy/QII/Pay for performance.aspx Rosenthal, M. (2006). How Will Paying for Performance Affect Patient Care?. Virtual Mentor, 8, 162-165.

Inter professional Team Working Risk Management Resuscitation department

Inter professional Team Working Risk Management Resuscitation department This assignment focuses on teamwork and the management of patients requiring emergency treatment. In health care, teamwork or inter-professional collaboration is an essential component of safety. As breakdowns in teamwork can lead to poor patient safety, I aim to critically evaluate and defend the importance of inter-professional collaboration in the resuscitation department. Example scenarios of patients that were brought into the resuscitation department requiring immediate care management will illustrate different team approaches to working, barriers to effective team working, and leadership of teams. The nurses role in the maintaining patient safety via risk management strategies will also be explored. This is important because the resuscitation department is a fast paced environment potentially vulnerable to risks. I intend to conclude how each scenario was managed and from these, draw up recommendations for streamlined nursing care and inter-professional team working in a resus citation department. A reference list is included. Introduction In the Accident and Emergency (AE) department, a key function is to receive asses and treat injured or sick people quickly at any time of the day or night. Anything can appear in an AE department; from patients with cuts, sprains and limb fractures, to patients with more serious life threatening conditions such as cardiovascular emergencies, gastrointestinal problems, neurovascular emergencies and traumatic injuries. Due to the nature of work in this environment, nursing care and management often occurs as a rapid sequence of events commencing with the recognition of life-threatening needs (Etherington 2003). Patients attending AE are seen immediately and there needs for treatment assessed. This initial assessment is a process known as triage designed to allocate clinical priority (See appendix). The Manchester triage group set up in 1994 is the most widely used triage method in the UK. The system selects patients with the highest priority first and works without making any assumptions about diagnosis. This is deliberate as AE departments are largely driven by patients presenting with signs and symptoms (Mackaway-Jones 1997). Once patients are triaged they are categorised according to a scale of urgency. The triage scale is colour coded for example: patients requiring immediate resuscitation and treatment are coded red, and would normally be met by a team standing by after prior notification by the ambulance service (Crouch and Marrow 1996). People presenting with serious injury or illness require a skilled team who follow recognised life support protocols within agreed roles (Etherington 2003). This assignment will focus on red coded patients brought into a resuscitation department requiring immediate care management for the preservation of life. Effective management of these patients is pivotal in reducing mortality rates and a skilled team is of great importance. In health care, teamwork or inter-professional collaboration is an essential component of safety. Research suggests that improvement in patient safety can be made by drawing on the science of team effectiveness (Salas, Rosen and king 2007). However, literature regarding emergency teams suggests that human factors such as communication and inter-professional relationships, can affect a teams performance regardless of how clinically skilled the team members are (Cole Crichton 2006, Lynch and Cole 2006). Ineffective teamwork can lead to errors in diagnosis and treatment (Salas, Rosen and king 2007) and is apparent in the many accusations of poor care and inadequate communication evident in malpractice lawsuits (Gro ff 2003). As breakdowns in teamwork can lead to poor patient safety, I aim to critically evaluate and defend the importance of inter-professional collaboration in the resuscitation department. Example scenarios of patients that were brought into the resuscitation department requiring immediate care management will illustrate different team approaches to working, barriers to effective team working, and leadership of teams. The nurses role in the maintaining patient safety via risk management strategies will also be explored. This is important because the resuscitation department is a fast paced environment potentially vulnerable to risks. I intend to conclude how each scenario was managed and from these, draw up recommendations for streamlined nursing care and inter-professional team working in a resuscitation department. Throughout this essay, I will adhere to confidentiality as stated in the Nursing Midwifery Councils Code (2008) and no identities regarding the patients or the trust shall be named. I acknowledge that some reference sources used in this assignment are dated, however they are still commonly cited in much up-to-date literature. The resuscitation room and the nurses role The resuscitation room is designed for the assessment and treatment of patients whose injury or illness is life-threatening (Etherington 2003). Anything can emerge with little warning (Walsh and Kent 2000) however, departments often receive prior warning of a patients arrival which allows the preparation of the resuscitation area and the team (Etherington 2003). All team members should be appropriately prepared to care for the patient in a systematic manner. AE nurses are vital components of the team (Hadfield-Law 2000) because they are usually among the first team members to meet patients and typically remain with them throughout their stay within the department (OMahoney 2005). A nurse with advanced life support (ALS) training is best placed to care for patients in the resuscitation room (Etherington 2003). This is where their training can be best utilized and this assists the inter-professional team to practice mutual working skills modelled on evidenced based protocols (DH 2005). Successful resuscitation depends on a number of factors, many of which can be influenced by AE nurses such as the environment and the equipment. Patient (2007) highlights various elements of AE nurses role in the preparation for patient arrival. This would include preparing the area, having equipment in ready and working order and having a team on stand by. These tasks underline the risk management strategies involved in maintaining a safe environment such as checking and cleaning everything on a regular basis (Etherington 2003), a practice which I observed is routinely carried between patient occupancy. The importance of carrying out such checks contributes to teams being prepared with equipment ready and working to treat patients safely. Once the patient has arrived, other roles and tasks the AE nurse might undertake include: maintaining a patients airway, patient assessment, taking vital observations, monitoring intravenous therapy, managing wound care, pain management, keeping rubbish clear to maintain a safe working environment, catheterisation, and communication and liaison between patients, relatives and the inter-professional team (Patient 2007, Etherington 2003). McCloskey et al., (1996) cited in Drach-Zahavy and Dagan (2002) describe this linking role of nursing as glue function as it is nurses who maintain the holistic overview of the care given to the patient by all members of the inter-professional team. From the literature (Patient 2007, Etherington 2003, McCloskey et al., 1996), it is evident that nurses working in the resuscitation area must be able to integrate with the inter-professional team and not only maintain the safety of the patient, but also everyone working in that environment. It is the nurses responsibility to manage the resuscitation room which incorporates preparing the environment and ensuring equipment is in working order. Investigation into the resuscitation room and the nurses role within that area has highlighted that nurses have many important management roles to carry out. For the purpose of this assignment, focus will be upon the nurse working as part of the inter-professional team, and the risk management strategies that take place to support that team. I had the opportunity to observe how inter-professional teams worked together to benefit the patient and ensure safety. Two examples of patients brought into the resuscitation department within the same week will now illustrate different team approaches to care management. Example 1 10:00 Saturday morning, the department receives a call from ambulance control warning that they have a patient with cardiac arrest on the way in approximately ten minutes. Immediately the lead nurse of the emergency department informs the two nurses managing the resuscitation department of the patient en route. The Nurses put a call out to the emergency inter-professional team to stand by and prepared the area by having the defibrillator in position, the oxygen mask ready and the adrenaline at hand. The emergency inter-professional team start flooding into the area and there is a mixture of bodies standing around in rubber gloves and aprons. The team consisted of three nurses, an anaesthetist, a physicians assistant, two junior medical students, two nursing students, a registrar, and a consultant equating 11 people. The ambulance crew arrived and they rushed the patient in promptly transferring her over from stretcher to trolley. The paramedic commenced a detailed handover to the team. The patient was a 69 year old woman who was found unconscious and not breathing at a holiday camp. The ambulance crew had been doing cardiac pulmonary resuscitation (CPR) for 45 minutes from scene to hospital. The patient was still not breathing. During the time of this handover, it was observed by the nurse that there was a short hesitancy between continuity of CPR. After the ambulance crew transferred the woman over to the trolley, no one took the lead of directing the team or continuing CPR. After this brief hesitancy a nurse took the lead by suggesting someone start CPR. Another nurse then stepped forward and commenced chest compressions whilst the anaesthetist placed a bag and mask over the patients airway. The team crowded around and the consultant stepped forward and started making orders loudly in relation to current advanced resuscitation guidelines. The defibrillator was attached and the team was advised by the nurse operating it to stand clear. Shocks were delivered without success. The team took it in turn to do chest compressions for fifteen minutes whilst other members gathered around obtaining intravenous access. The consultant then suggested that they stop. The team stood back and started to disperse out of the resuscitation room leaving the nurses to continue care and management of the patient and her family. The patient was disconnected from the defibrillator and a nurse cleaned the resuscitation area. Example 2 At 02:30 ambulance control report that they have a patient involved in a road traffic collision (RTC) on route due in approximately twenty minutes. The lead nurse informs the two nurses running the resuscitation area who then inform the inter-professional team to stand by. The resuscitation area is prepared and a team of seven including two nurses, a registrar, an anaesthetist, a physicians assistant, an orthopaedic doctor, and a nursing student await the patients arrival. The team pre-decided on who is to do what tasks. The ambulance crew arrive with the patient on a spinal board. The crew hand over the patient, a 42 year old male who was intoxicated with alcohol and overdosed on analgesics, had been involved in a high-speed police chase and sped off the road overturning his car and going through the windscreen. The patient had recently discovered that his wife was having an affair and this was the suspected cause of his actions. The police awaited outside the resuscitation department. The patient was semi conscious maintaining his own airway. The registrar took the medical lead advising calmly who to do what. The anaesthetist took the management of the airway, a nurse provided comfort and reassurance to the patient whist taking observations. Another nurse cut the patients clothes off him and covered him with sheets. The protocol used for patients involved in trauma is the Advanced Trauma Life Support (ATLS) system (American College of Surgeons 1997) which is a widely adopted management plan for trauma victims. Initial assessment consists of preparation, a primary survey, resuscitation, secondary survey and definitive care phase which is the ongoing management of trauma. Because the ATLS involves medical and nursing staff, they encourage inter-professional learning. This occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care (DH 2007). Most AE departments use the ATLS protocols (Etherington 2003) as this system of managing the severely injured has now become part of best practice (Royal College of Surgeons 2000). The registrar and the nurses all appeared highly familiar with ATLS protocol and a primary survey, secondary survey followed by definitive care phase was carried out systemically and smoothly. The team anticipated each others actions and care management resulted in the patient being able to maintain his own airway, breathing and circulation. Other team members that became involved in the care management of this patient included the radiographer, lab technicians and the police. The nurses liaised with all these people and acted as a mediator of communication between the team. This reinforces Drach-Zahavy and Dagans (2002) concept of glue function as it is nurses who maintain the holistic overview of the care given to the patient by all members of the inter-professional team. It is worth noting that these examples are comparatively different in relation to the time of day they occurred, the teams that attended, and the age and presentation of the patients. These factors will be taken into consideration during discussion of the two examples. Inter-professional team working Nurses are obliged to adhere to the NMC Code which in relation to team working, clearly states that nurses must work effectively as part of a team and respect the skills, expertise and contributions of colleagues (NMC 2008). The importance of inter-professional working has been emphasised in a succession of government white papers addressing care (Hewison 2004) which call for more team working, extended roles for professionals and the removal of hindrances to collaboration (DH 2000a/b, 2004, 2005). During a critical care emergency, effective teamwork, prioritising and speed of care delivery may mean the difference between life and death (Denton and Giddins 2009). National Patient Safety Agency (NPSA 2008) and National Institute for Health and Clinical Excellence (NICE 2007) agree that healthcare professionals are required to be able to respond appropriately in emergency situations. This entails an up-to-date knowledge of current evidence-based resuscitation guidelines (Resuscitation Council 2005, 2006) and the need for a team approach to care management of acutely ill individuals (Denton and Giddins 2009). An exploration of inter-professional team working in a resuscitation area will now follow, using the above examples to appraise the importance of inter-professional collaboration. Teams and team effectiveness will be discussed as this is essential in identifying the mechanisms of teamwork involved in patient management and safety (Salas, Rosen and King 2007). The DH (2005) recognise that outcomes of health care services are a product of teamwork and, the use of the word team is a broad spectrum term aimed to include all healthcare professionals working inter-professionally. Mohrman et al., (1995) definition includes individuals who work together to deliver services for which they are mutually accountable and, integrating with one another is included among the responsibilities of each member. Leathard (1994) depicts inter-professional practice to refer to people with distinct disciplinary training, working together making different yet complementary contributions to patient focused care. The philosophy of care in the local AE department incorporates these definitions stating; professionals aim to promote team spirit with support to each other and encourage relations with other disciplines (Trust AE nursing philosophy 2008). Salas, Rosen and King (2007) suggest effective teams have several unique characteristics including: a dynamic social interaction with significant interdependencies, a discrete lifespan, a distributed expertise, clearly assigned roles and responsibilities, and shared common values and beliefs (Wiles and Robinson 1994). These characteristics require goal directedness, communication and flexibility between members (Webster 2002). From these definitions, it is apparent that in healthcare a common and vital feature in teamwork is shared values and goals (Salas, Rosen and King 2007, Wiles and Robinson 1994). This serves as the teams focus point and appears to be at the pinnacle of what members strive towards. In example 1, shared values and goals are evident in the ALS protocols that the team followed. However, individuals roles were not clearly recognised and the team did not seem to be familiar with one-another. In example 2, the team again demonstrated shared values and goals by following agreed protocols (ATLS). This was further demonstrated in how the team interacted with each other and anticipated one-anothers actions. Pre-agreed tasks were organised by the team and they demonstrated mutual understanding of one-anothers roles. When members of trauma teams are given pre-assigned roles, they can perform a practice known as horizontal organisation which refers to the ability of performing several interventions simultaneously (Patient 2007 and Cole 2004). Taking on pre-agreed roles and responsibilities can influence patient outcomes, limiting resuscitation times and lowering mortality rates (Lomas and Goodall 1994). Salas, Rosen and King (2007) advise teams take time to develop a discipline of pre-brief where the team clarifies the goals, roles and performance strategies required. Example 2 demonstrates how, this preparation is proven to amplify performance levels when functioning under stressful conditions (Inzana et al., 1996 cited in Salas, Rosen and King 2007). A team approach in resuscitation has proved highly effective in reducing mortality rates (Walsh and Kent 2000). However, evidence suggests that human factors such as poor communication and lack of understanding of team members roles can breakdown team effectiveness leading to poor patient safety. (Xyrichis and Ream 2008, Atwal and Caldwell 2006). In relation to example 1, there were many team members present; nobody knew clearly who was who. To understand what makes an effective team, barriers inter-professional teams face and what can be done to overcome these obstacles shall be explored. Barriers to Inter-professional team working We have established that emergency care management involves many professionals each with their own discipline, knowledge and skills. Due to this diversity, professionals may have limited knowledge of each others roles and so undervalue the contribution of care delivered to patients, making inter-professional team working difficult (Spry 2006). Also, the way which individuals work together depends greatly on personalities and individual compatibility (Webster 2002). If personalities clash, this is a barrier to team effectiveness. In example 2, the team were familiar with one another and had evidently worked together in many trauma care situations as they seemed to trust and respect each other. This team were on their 3rd consecutive night shift working together therefore they had built a rapport with each other. Similarly in Cole and Crichtons (2006) study exploring the culture of a trauma team in relation to influencing human factors, many respondents described an amity and familiarity. They argued that teams work when people know their roles, have the required technical expertise and are knowledgeable about trauma. Cole and Crichton (2006) interviewed a consultant team leader who reports; you can have the most gruesome scenario where you have a new surgical SHO and a new anaesthetic SHO, no-one knows each other and its atrocious! Teams made up of individuals who are familiar with each other work with greater efficacy than teams composed of strangers (Guzzo and Dickson 1996 cited in Cole and Crichton 2006). This report illustrates the challenges that team unfamiliarity poses. In Cole and Crichtons (2006) study, focused ethnography was used to explore the culture of a trauma team in a teaching hospital. Many ethnographic studies focus on a distinct problem amongst a small group. This method is appropriate when focussing on the meanings of individuals customs and behaviours in the environment in which they are occurring (Savage 2000). Six periods of observation of trauma teams attending trauma calls was undertaken followed by 11 semi-structured interviews with purposively chosen key personnel. Their findings are based on the trauma teams working in one hospital; therefore this study is quite narrow. Cole and Crichton acknowledge that this method of study can be criticized for producing only one snapshot in time, potentially reducing its credibility. Taking these limitations into account, I believe their findings could be used to inform best practice where if the opportunity existed teams could be facilitated to practice working together. This would allow me mbers to become familiar with each others personalities and roles. Teams operating within an emergency medicine context face complex, dynamic and high-stress environments (Salas, Rosen and King 2007). However Denton and Giddins (2009) suggest staff in these areas become experienced in managing emergencies, know each others roles and have developed close team-working skills. Example 2 shows evidence to support this. Conversely, in example 1, the team seemed disjointed and nobody seemed to know each other. They assembled for the resuscitation but a lack of role perception hindered the teams ability to work effectively together. Research into inter-professional team working and resuscitation attempts is limited (Denton and Giddins 2009). However, a small study of cardiopulmonary resuscitation conducted in a trust hospital by Meerabeau and Page (1999) found that, although team members of a resuscitation attempt may have a common goal (to resuscitate the patient) and some of the attributes associated with effective teams, many features may not be present . These features encompass regular interaction and clear roles as their evidence concludes, CPR teams generally did not work together nor practice their skills together. These findings support Cole and Crichtons (2006) results and could be applicable to example 1 indicating that; although CPR teams trained specifically to react in CPR situations, factors such as regular interaction and clear roles influence team effectiveness. If integrated inter-professional working is to become a reality, it is fundamental that people have opportunities to work closely together to build up personal relationships and understand others roles (Hewison 2004). Professional education needs to play a vital part in supporting this (Webster 2002). The DH actively encouraged initiatives in the NHS and in higher education institutions to encourage greater role awareness amongst health professionals and support effective team working (DH 2007, 2004a, 2000b). This allows team members to devise precise expectations of their team mates actions and requirements during high-stress work episodes (Salas, Rosen and King 2007). This is a logical solution but like Salas, Rosen and King (2007) note, teams come together for a discrete lifespan and depend upon who is on duty and time of day. Consequently having opportunities for developing personal relationships and understanding each others roles becomes a challenge. A lack of specialist skills required to manage the care of critically ill patients is a potential barrier to delivering effective team care as this could escalate into inter-professional conflict. This is when nurses skills and doctors expectations of these skills differed (Tippins 2005). This barrier highlights the relevance of the ATLS training. Patient (2007) confirms that individuals who have undertaken the ATLS course claim they have gained an insight into each others roles and resultantly, can communicate with one another better (Hadfield-Law 1994). The number of staff available varies between departments and is influenced by time of day (Etherington 2003). Example 1 took place on a busy Saturday morning and the department was bustling with staff. The team that attended to the patient was large and appeared disorganised. There were 11 members to this team, 4 of which were students who were perhaps encouraged to attend and observe the situation. The team that attended the patient in example 2 was comparatively smaller and appeared more organised. In an article by Tippins (2005) exploring nurses experiences of managing critical illness in an AE department, one nurse describes how the nature of the experiences depended on the size and dynamics of a team: Because it was such a big trauma, there were so many people there, actually you feel its not managed very well because there were so many people. It was just a bit chaotic really. This example along with example 1 demonstrates that large numbers of people can make inter-professiona l working difficult. The ideal number of team members in a resuscitation team is uncertain (Patient 2007). Etherington (2003) reinforces that effective teamwork is possible with just 3 people present providing leadership, trust and collaboration are achieved. Relating back to example 2, leadership, trust and collaboration was evident. There was also a strong awareness of roles and task distribution as opposed to example 1 where the team appeared to gather in an unorganised fashion. These examples demonstrate that the size of a team does not reflect quality. It is influencing factors such as role perception, communication and good leadership that make an effective team. Within inter-professional teams individuals also need emotional intelligence to work effectively with colleagues and patients (Mc Callin and Bamford 2007). According to Goleman (1998), someone with high emotional intelligence is aware of emotions and how to regulate them and use this data to guide their thinking and actions (Faugier and Woolnough 2002). Self-awareness, social awareness and social skill are central to emotional intelligence. This is the heart of effective teamwork and influences excellence and job satisfaction (Mc Callin and Bamford 2007). The team in example 2 displayed emotional intelligence in their interactions amongst each other and the patient. For example, the registrar and the nurses constantly communicated with the patient recognising his distress. Team members also displayed horizontal organization demonstrating their awareness and anticipation of one anothers roles and task allocation. Breakdown in communication has been highlighted a root cause of serious incidents (National Patient Safety Agency 2006) and trauma resuscitations are especially vulnerable. Heavy workload and constantly changing staff can inhibit communication between team members and so affect adversely patient outcomes for example; medication errors or amputation of wrong limbs (Lynch and Cole 2006). Salas, Rosen and King (2007) highlight how communication often breaks down in the inherently stressful nature of responding to crises which can consequently result in clinical errors during decision making. Paradoxically, this is when communication needs to be at its finest (Haire 1998). Many examples of high-quality nursing practice in managing critically ill patients involve good communication skills between staff, patients and relatives (Tippins 2005). Good communication begins and ends with self (Dickensen-Hazard and Root 2000). This relates back to the concept of emotional intelligence and awareness where every person, particularly the leader, should have a clear picture of self, of what is valued and believed and how that blends with the organisation served. Overall, clear, precise and direct channels of communication need to be in place to enhance patient outcome, team functioning (Haire 1998), patient safety and quality care. Leadership The concept of inter-professional team working and the barriers that hinder team effectiveness has been discussed. Now an analysis on team leadership will follow. Leadership is defined as a particular form of selected behaviour that manages team activity and develops team and individual performance (Lynch and Cole 2006). There is a strong focus on leadership within the health service as a resource for delivering quality care and treatment. This is noted in the NHS plan (DH 2000b) which states: Delivering the plans radical change programme will require first class leaders at all levels of NHS. By having visible leaders at all levels contributes to setting high standards and amending errors efficiently. Consequently this contributes to maintaining a safe environment. A resuscitation team needs a visible leader who has the knowledge and communication skills to direct team members (Etherington 2003). In relation to example 1, there was no immediate visible leader who took the task of preparing the team. Only later did the consultant take the lead. As suggested earlier, resuscitation teams are effective when team members adopt specific, pre-agreed roles, which can be carried out simultaneously. The consultant was unable to prepare the team as he arrived only seconds prior to the patient. In the AE department, effective leadership is of prime importance due to the fast paced nature of the environment, which lends potential for staff to feel threatened by the perceived chaos. The leader needs to foster an environment where care delivery has some structure, and staff have guidance and security (Cook and Holt 2000). This role of team leader is pivotal for the effective functioning of the team (Cole and Crichton 2006). The consultant in example 1 and the registrar in example 2 were the identified team leaders. There are few recommendations made about the education necessary to become a team leader other than experience and seniority. The Royal College of Surgeons (2000) report that the team leader should be experienced in emergency management from either an emergency, intensive care or surgical specialty and have completed an ATLS course (Cole and Crichton 2006, American College of Surgeons 1997). From observation of leadership in the local resuscitation department, it appears that the most senior team member takes the lead. Etherington (2003) argues that many AE nurses perform the leader role as well as their medical colleagues. Meanwhile, Gilligan et al., (2005) argue that in many emergency departments AE nurses do not assume a lead role in advanced resuscitation. Their study investigated whether emergency nurses with previous ALS training provided good team leadership in a simulated cardiac arrest situation concluding that, ALS trained nurses performed equally as well as ALS trained emergency Senior House Officers (SHOs). This study was conducted at five emergency departments. All participants went through the same scenario. Participants included 20 ALS trained nurses, 19 ALS trained emergency SHOs, and 18 emergency SHOs without formal ALS training. The overall mean score for doctors without ALS training was 69.5%, compared with 72.3% for ALS trained doctors and 73.7% for ALS trained nurses. The evidence drawn from Gilligan et al., (2005) suggests it may be