Teamwork and Collaboration Nursing CE Course

There may be hurdles to overcome in fostering a team collaboration environment, such as additional time, a perceived loss of autonomy, a lack of confidence or trust in the decisions of others, clashing perspectives, territorialism, and a lack of awareness of the education, knowledge, and skills held by colleagues from other disciplines and professions. However, most of these hurdles can be overcome with an open-minded attitude and feelings of mutual respect and trust. A study determined that healthcare workers described improved teamwork and communication as among the most critical factors in improving clinical effectiveness and job satisfaction (O'Daniel & Rosenstein, 2008). 

Effective Communication 

Communication errors are an independent contributing factor leading to preventable patient harm. Since communication is a crucial part of everyday work and necessary for patient safety, organizations must recognize the value of teamwork and strive to improve communication within the team. In a team approach, members recognize the boundaries of each discipline and value everyone's contribution. Teamwork methods must be adapted in the workplace to create an environment where all levels of staff work together and respect each other's opinions (Kearney-Nunnery, 2020; Rosen et al., 2018). 

Nurses must communicate effectively with a diverse group of professionals and unlicensed personnel in caring for patients. When healthcare team members communicate ineffectively, healthcare delivery to patients suffers. This finding has prompted several healthcare organizations, including the Institute of Medicine (IOM) and the Agency for Healthcare Research and Quality (AHRQ), to call for an improvement in communication skills among healthcare workers (Kearny-Nunnery, 2020).  

The Joint Commission also addressed communication in its 2022 National Patient Safety Goals for Hospitals. Goal #2 is to "improve staff communication." This goal explicitly addresses the need to report critical results of tests and diagnostic procedures promptly to the correct individual. Critical results of tests and diagnostic procedures fall significantly outside the normal range and may indicate a life-threatening situation. The objective is to provide the responsible licensed caregiver with these results within an established time frame so the patient can be promptly treated. Institutions should develop written procedures for managing critical results of tests and diagnostic procedures that address the following: the definition of critical results of tests and diagnostic procedures, by whom and to whom critical results are reported, and the acceptable length of time between the availability and reporting of critical results (The Joint Commission, 2021). 

One of the essential elements of human interaction is the ability to communicate. Communication, particularly in high-intensity environments such as healthcare settings, is not merely the transaction of words. Effective communication requires an understanding of the underlying context of the situation, an appreciation for the tone and emotions of a conversation, and accurate information. When implemented consistently, the principles of effective communication can bridge the figurative divide between different departments and licensed versus non-licensed staff and ensure a reliable and dynamic means of relaying information and feedback. According to the American Nurses Association (ANA) and American Organization of Nurse Executives (AONE), principles of effective communication include the following: 

• engaging in active listening to fully understand and contemplate what is being relayed 

• knowing and understanding the intent of a message and the purpose and expectations of that message 

• fostering an open, safe environment for communication 

• ensuring information that is being given or received is accurate 

• having individuals speak directly to the correct person (ANA & AONE, 2019) 

Professional Collaboration  

To illustrate a highly effective practice environment, the ANA and the AONE convened a group of clinical nurses and nurse managers to develop Principles of Collaborative Relationships. The principles include effective communication, authentic relationships, and a supportive learning environment and culture. These principles guide all nurses in their synergistic role to create, enhance, and sustain collaborative relationships. When working relationships are strong and effective, nurses function as a team and deliver on their shared goal of high-value care (ANA & AONE, 2019). 

In collaboration, there is no implied supervision: it is a 2-way exchange of information. The relationship between individuals who are collaborating is nonhierarchical. The power is shared and based on each individual's knowledge and expertise in the setting, not their role or title. When there is true collaboration in the workplace, the responsibility for the patient is shared; the professionalism of all is strengthened when each group member has participated and obtained success. Each professional's unique perspective on a situation results in creative and practical solutions; in turn, the patient's well-being is the ultimate beneficiary. To practice effective communication in the workplace, everyone must be willing to participate equally. Collaboration is significantly more complex than simply working closely. It implies a joining together and a degree of caring about each other. A collaborative relationship is not merely the sum of its parts but a synergistic alliance that maximizes each participant's contributions, resulting in greater action than the sum of individual efforts (Kearney-Nunnery, 2020). 

Authentic Relationships  

Professional nurses cultivate caring relationships with their patients, supporting them in meeting their physical, mental, and spiritual needs related to health. To bolster the profession and the quality of care patients receive, nurses must also build intentional professional relationships with each other. Nurses engage in the art and science of caring; by their very nature, they thrive when they experience caring from their colleagues. The principles of authentic relationships guide nurses to develop these interactions with colleagues and cultivate their sense of being cared for, promoting their ability to do the same for their patients. The ANA and AONE's (2019) principles of authentic relationships include:  

• Be true to yourself: be sure your actions match your words and reflect integrity.  

• Empower others to have, share, and enact their ideas.  

• Recognize and leverage each other's strengths.  

• Be honest 100% of the time – with yourself and others. 

• Respect others' personalities, needs, and wants.  

• Ask for what you want but stay open to negotiating differences.  

• Assume good intent from others' words and actions. 

Establishing a Culture of Support 

One of the first crucial steps is organizational commitment and willingness to address teamwork and collaboration. Commitment needs to come from leadership, highlighting how the organization does business. The focus should be on behavioral standards and their relationship to patient safety. Addressing defects in communication that affect collaboration, information exchange, appreciation of roles and responsibilities, and direct accountability for patient care are vital components of any patient safety program. Clinical and administrative leaders must set the tone by establishing and adhering to behavioral standards that support the agreed-upon code of conduct practices backed by a nonpunitive reporting culture and zero-tolerance policy (O'Daniel & Rosenstein, 2008). 

The next step in the process is recognition and self-awareness. Organizations must be able to assess the prevalence, context, and impact of behaviors to identify potential opportunities for improvement. Completing an internal assessment will help pinpoint the seriousness of the situation and provide clues about which areas need to be addressed. Assessment information can be gained from formal methods such as incident reports, survey tools, focus groups, department meetings, task forces or committees, direct observation, suggestion boxes, and hotlines. Informal methods such as casual meetings and conversations can also provide valuable preliminary information and should prompt further evaluation of the source, relevance, and significance of the data to determine the next steps (O'Daniel & Rosenstein, 2008). 

Creating formal and informal opportunities for different groups to gather is a highly effective strategy for enhancing collaboration and communication. Encouraging open dialogue, organizing collaborative rounds, implementing preoperative and postoperative team briefings, and creating interdisciplinary committees or task forces to discuss problem areas frequently provide an upfront solution that reduces the likelihood of disruptive events. When a disruptive event occurs, some organizations have implemented a time-out, code white, or red-light policy that addresses the issue in real-time to prevent further serious consequences (O'Daniel & Rosenstein, 2008). 

Developing and implementing a standard set of behavior policies and procedures is vital. These policies need to be consistent and universally applied. There should not be a separate policy for any particular disciplines or services. The policy should include a standardized protocol outlining expected standards and the process for addressing disruptive behavior issues, recommendations, follow-up plans, and actions to be taken if individuals resist or refuse to comply. Before implementation, education is needed to ensure all employees are familiar with the policies and procedures' existence, purpose, and content. The organization needs to encourage all employees to report disruptive behaviors for the process to work successfully. The organization needs to address issues related to confidentiality, fear of retaliation, and the familiar sentiments that there is a double standard for particular disciplines and that nothing ever changes despite reporting incidents or speaking up. Reporting mechanisms should be user-friendly and supported by a nonpunitive environment. The ideal situation is to address the behavior in real-time, but concerns about position, appropriateness, receptiveness, fear, hostility, and retaliation are significant impediments. Appropriate avenues for reporting may include reporting the incident to a superior, filing an incident report, using a complaint or suggestion box, or reporting directly to a task force or interdisciplinary committee responsible for addressing these issues. Besides maintaining confidentiality and reducing the risk of retaliation, one of the most crucial aspects of the reporting system is recognizing and ensuring complaints will be addressed and corresponding actions are taken. Responses should be timely, appropriate, and consistent while providing necessary feedback and follow-up opportunities (O'Daniel & Rosenstein, 2008).  

The next step is taking action through appropriate intervention strategies. Generic educational programs can help spread the message and teach basic communication skills. Relevant topics include sessions on team dynamics, communication skills, phone etiquette, assertiveness training, diversity training, conflict management, stress management, and any other courses necessary to foster more effective team functioning and communication. Another essential strategy is promoting and providing competency training to all healthcare team members. This is a crucial factor affecting trust and respect, which strongly influences team collaboration. Focused team training programs have been of particular value. Having a clinical champion or an early adopter who actively promotes the importance of appropriate behavior, communication, and team collaboration can be an extremely valuable asset. Champions can come from the executive ranks or other staff members' voluntary interest and enthusiasm. Co-champions may even be more effective. Some organizations have reported that having a nurse and physician (or another healthcare professional) complete a joint training program will help foster cooperation and collaboration between different disciplines. Follow-up and feedback bring closure to the process. Participants must know that their input is welcomed, follow-up actions will be taken, and appropriate feedback will be provided (O'Daniel & Rosenstein, 2008). 

Mutual Respect  

Mutual respect is of the utmost importance among all healthcare team members and must be valued by everyone. In addition, all hierarchies must be eliminated to encourage collaborative practice. Hierarchy is also a barrier to communication. For example, some older male physicians may expect nurses (historically a position filled by women) to be subservient and make fewer contributions on a professional level (Kearney-Nunnery, 2020).  

According to Grenny and colleagues (2021), writing in Crucial Conversations: Tools for Talking When Stakes are High, mutual respect is the continuance condition of dialogue. People cannot stay in a conversation if they do not have mutual respect. If people perceive that others do not respect them, the conversation immediately comes to a halt. Respect is like air. If you take it away, it's all people can think about. The instant people perceive disrespect in a conversation, the interaction is no longer about the original purpose: it is now about defending dignity (Grenny et al., 2021). 

Teamwork 

Effective teams are characterized by shared purpose and intent, trust, respect, and collaboration. Team members value familiarity over formality and watch out for each other to ensure mistakes are not made. Healthcare teams that do not trust, respect, and collaborate are more likely to make a mistake that could negatively impact the safety of patients (O'Daniel & Rosenstein, 2008). 

In a 2002 work entitled The Five Dysfunctions of a Team, Patrick Lencioni points to 5 dysfunctions that create obstacles for even the best teams. He outlines a model with actionable steps that can be used to overcome these common hurdles and build cohesive, effective teams. Lencioni identifies the following dysfunctions and positive characteristics that may overcome each dysfunction (see Figure 1 below; Lencioni, 2002): 

• Absence of Trust: Trust is confidence among team members that their peers' intentions are good and that there is no reason to be protective or careful around the group. Members of trusting teams: 

  • admit weaknesses and mistakes 

  • ask for help 

  • accept questions and input about their area of responsibility 

  • give one another the benefit of the doubt before arriving at a negative attribute 

  • take a risk in offering feedback and assistance 

  • appreciate and tap into each other's skills and experiences 

  • focus time and energy on important issues, not politics 

  • offer and accept apologies without hesitation 

  • look forward to meetings and opportunities to work as a group 

• Fear of Conflict: It is crucial to distinguish productive ideological conflict from destructive fighting and interpersonal politics. The purpose is to produce the best possible solution in the shortest period. Teams that engage in healthy conflict: 

  • have lively, interesting meetings 

  • extract and employ the ideas of all team members 

  • solve real problems quickly 

  • minimize politics 

  • put critical topics on the table for discussion 

• Lack of Commitment: In the context of teams, commitment is a function of clarity and buy-in. Great teams make clear and timely decisions and move forward with complete buy-in from every team member, even those who voted against the decision. The most significant causes of a lack of commitment are the desire for consensus and the need for certainty. A team that commits: 

  • creates clarity around directions and priorities 

  • aligns the entire team around common objectives 

  • develops an ability to learn from mistakes 

  • takes advantage of opportunities before competitors do 

  • moves forward without hesitation 

  • changes direction without hesitation or guilt  

• Avoidance of Accountability: In the context of teamwork, accountability refers specifically to the willingness of team members to point out performance or behaviors that might hurt the team. A team that holds one another accountable: 

  • ensures that poor performers feel the pressure to improve 

  • identifies potential problems quickly by questioning one another's approaches without hesitation 

  • establishes respect among team members who are held to the same high standards 

  • avoids excessive bureaucracy around performance management and corrective action 

• Inattention to Results: A team's ultimate dysfunction is members' tendency to care about something other than the group's collective goals. An unrelenting focus on specific objectives and clearly defined outcomes are required for any team that judges itself on performance. A team that focuses on collective results: 

  • retains achievement-oriented employees 

  • minimizes individualistic behavior 

  • enjoys success and suffers failure acutely 

  • benefits from individuals who subjugate their own goals/interests for the good of the team 

  • avoids distractions 

Strategies to Improve Interdisciplinary Collaboration 

In 2005, the Agency for Healthcare Research and Quality collaborated with the US Department of Defense to develop the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS). This evidence-based patient safety toolkit addresses the leading causes of medical errors. It helps organizations and healthcare professionals (HCPs) improve healthcare delivery quality, safety, and efficiency through effective communication and teamwork skills. Many hospitals and care systems use the TeamSTEPPS framework to improve their culture and patient safety. TeamSTEPPS training has driven measurable quality improvement in various delivery areas utilizing a framework of 4 core competencies (see Figure 2 below; Health Research & Educational Trust, 2015):  

• Communication: effectively exchange information among team members, regardless of how it is communicated. 

• Leadership: direct and coordinate, assign tasks, motivate team members, and facilitate optimal performance. 

• Situation monitoring: develop shared understandings of the team environment, apply strategies to monitor team members' performance, and maintain a shared mental model. 

• Mutual support: anticipate other team members' needs through accurate knowledge and shift workloads to achieve balance during periods of high workload or stress. 

There are three phases of TeamSTEPPS implementation. For the intervention to be effective, a hospital or care system should complete key actions through each phase:  

• Phase One - Assessment 

  • determine the organization's readiness by conducting a training needs analysis 

  • establish a multidisciplinary change team at the organizational level 

  • identify challenges and opportunities for improvement 

  • develop goals for the intervention 

• Phase Two - Planning, training, and implementation 

  • define the TeamSTEPPS intervention and develop a plan for its effectiveness 

  • draft an implementation plan and communication plan to prepare the organization 

  • systematically implement TeamSTEPPS intervention through training 

• Phase Three - Sustainment 

  • establish a sustainment plan to practice TeamSTEPPS principles 

  • engage leadership to emphasize new skills and practices with regular feedback 

  • celebrate wins to bolster engagement in teamwork 

  • measure the intervention's effectiveness 

  • update the plan (Health Research & Educational Trust, 2015) 

Various other teamwork tools can be implemented to enhance patient safety (see Table 1).  

Nurse-Provider Collaboration 

Maximizing the effectiveness of nurse-provider communication is essential for creating more satisfying work roles and interdisciplinary collaboration. Nurse-provider collaboration can improve patient outcomes, lower healthcare costs, and maintain patient safety. Studies have shown that when communication between nurses and providers is unprofessional or inadequate, conflict can arise, leading to poor patient outcomes and medical errors. It has also been found that poor communication between providers and nurses influences nurse retention rates and shortages. This is often the case when providers maintain a hierarchical relationship with nurses and view them as assistants instead of partners in delivering patient care (Elsous et al., 2017).  

Although many communication tools are available, the SBAR tool (see Table 1) was initially implemented in the healthcare environment to facilitate better communication between nurses and providers. Using the SBAR is the gold standard for handoff reporting within healthcare. Many HCPs say that SBAR leads to a more precise and thorough handoff. At one institution, following the implementation of the SBAR format for handoff and communication, it was found that two-thirds of nurses had a good to high proficiency following the format, and two-thirds of providers reported receiving a report that was adequate to make informed clinical decisions (Shahid & Thomas, 2018).   

Conclusion  

Effective clinical practice must not only focus on technological system issues but also on the human factor. Strong communication encourages collaboration and helps prevent errors. Healthcare organizations must assess possible setups for poor communication and be diligent about offering programs and outlets to help foster team collaboration. By addressing this issue, healthcare organizations have an opportunity to enhance their clinical outcomes significantly (O'Daniel & Rosenstein, 2008). 

References 

Agency for Healthcare Research and Quality. (2019). About TeamSTEPPS. TeamSTEPPS: national implementation [Image]. http://teamstepps.ahrq.gov/about-2cl3.htm 

American Nurses Association & American Organization of Nurses Executives. (2019). ANA/AONE principles for collaborative relationships between clinical nurses and nurse managers. https://www.aonl.org/resource-library/guiding-principles-collaborative-relationships-between-clinical-nurses-and-nurse-managers 

American Nurses Credentialing Center. (2020). Magnet model - creating a magnet culture. https://www.nursingworld.org/organizational-programs/magnet/magnet-model/ 

Elsous, A., Radwan, M., & Mohsen, S. (2017). Nurses and physicians attitudes toward nurse-physician collaboration: A survey from Gaza Strip, Palestine. Nursing Research and Practice, 2017(7406278). https://doi.org/10.1155/2017/7406278 

Grenny, J., Patterson, K., McMillan, R., Switzler, A., & Gregory, E. (2021). Crucial conversations: Tools for talking when the stakes are high (3rd ed.). McGraw-Hill. 

Health Research & Educational Trust. (2015). Improving patient safety culture through teamwork and communication: TeamSTEPPS. American Hospital Association. https://www.aha.org/ahahret-guides/2015-06-18-improving-patient-safety-culture-through-teamwork-and-communication 

The Joint Commission. (2021). Hospital national patient safety goals. https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2022/npsg_chapter_hap_jan2022.pdf 

Kearney-Nunnery, R. (2020). Advancing your career: Concepts of professional nursing (7th ed). F.A. Davis. 

Last, S. (n.d.). Lencioni model: Five dysfunctions of a team [Image]. Retrieved June 2, 2022, from https://pressbooks.bccampus.ca/technicalwriting/chapter/understandingteamdynamics/ 

Lencioni, P. (2002). The five dysfunctions of a team. Jossey-Bass. 

Praetorius, T., Hasle, P., & Nielson, A. (2018). No one can whistle a symphony: how hospitals design for daily cross-boundary collaboration. Journal of Health Organization &Management, 32(4), 618–634. 

Quality and Safety Education for Nurses (2020). Graduate QSEN competencies. https://qsen.org/competencies/graduate-ksas/ 

Rosen, M. A., DiazGranados, D., Dietz, A. S., Benishek, L. E., Thompson, D., Pronovost, P. J., & Weaver, S. J. (2018). Teamwork in healthcare: Key discoveries enabling safer, high-quality care. American Psychologist, 73(4), 433-450. https://doi.org/10.1037/amp0000298 

Shahid, S., & Thomas, S. (2018). Situation, background, assessment, recommendation (SBAR) communication handoff in health care – A narrative review. Safety in Health 4(7). https://doi.org/10.1186/s40886-018-0073-1