Teamwork and Collaboration Nursing CE Course

formation and feedback. Principles of effective communication according to the American Nurse’s Association (ANA) and American Organization of Nurse Executives (AONE) include:

• Engage in active listening to fully understand and contemplate what is being relayed. 
• Know the intent of a message, and what is the purpose and expectations of that message. 
• Foster an open, safe environment. 
• Whether giving or receiving information, be sure it is accurate. 
• Have people speak to the person they need to speak to, so the right person gets the right information (ANA/AONE, 2015, p.2).

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 Collaboration. These principles guide all nurses in their synergistic role to create, enhance, and sustain collaborative relationships.  When working relationships are strong and effective, nurses at all levels function as a team, and they deliver on their shared goal of high-value care (ANA/AONE, 2015).

In collaboration there is no implied supervision; it is a two-way exchange of information. The relationship between individuals who are collaborating is nonhierarchical. The power is shared and is based on the knowledge and expertise that each individual brings to the setting, not on 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 member of the group has participated and has obtained success. The unique perspective that each profession brings to a situation results in creative and practical solutions, and in turn, the patient's well-being is the ultimate beneficiary. To practice effective communication in the workplace setting, each individual must be willing to participate equally. Collaboration is significantly more complex than simply working in close proximity to one another. It implies a bond, a joining together, a union, and a degree of caring about one another and the relationship. A collaborative relationship is not merely the sum of its parts, but it is a synergistic alliance that maximizes the contributions of each participant resulting in action that is greater than the sum of individual works (Kearney-Nunnery, 2016).

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 our patients receive, nurses must reciprocate that kind of relationship with each other. As professionals, nurses engage in the art and science of caring, and by their very nature, nurses thrive when they experience caring from their colleagues.  The principles of authentic relationships gives the nurse a guide for developing these interactions with colleagues, and cultivates the nurse's sense of being cared for that promotes their ability to do the same for their patients. The ANA/AONE’s principles of authentic relationships includes: 

• Be true to yourself – be sure your actions match your words, and those around you are confident that what they see is what they get. 
• Empower others to have ideas, to share those ideas, and to participate in projects that leverage or enact those ideas. 
• Recognize and leverage each other’s strengths. 
• Be honest 100% of the time – with yourself, and with others.
• Respect others’ personalities, needs, and wants. 
• Ask for what you want, but stay open to negotiating the difference. 
• Assume good intent from others’ words and actions, and assume they are doing their best (ANA/AONE, 2015, p.2). 

Establishing a Culture to Support Communication and Team Collaboration

One of the first crucial steps is organizational commitment and willingness to address the situation. Commitment needs to come from the top down and the bottom up, making a statement about the way the organization does business. The rallying point should be around 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 key 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 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. Doing an internal assessment will help pinpoint the seriousness of the situation and provide clues about which areas may 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 gossip can also provide valuable preliminary information and should prompt further evaluation as to the source, relevance, and significance of the information to determine the next steps (O’Daniel & Rosenstein, 2008).

Creating opportunities for different groups to gather is a highly effective strategy for enhancing collaboration and communication. Group interactions can be either formal or informal. Encouraging open dialogue, organizing collaborative rounds, implementing preop and postop team briefings, and creating interdisciplinary committees or task forces to discuss problem areas frequently provides an upfront solution that reduces the likelihood of disruptive events. When a disruptive event does occur, some organizations have implemented a time-out, code white, or red-light policy that addresses the issue in real time to prevent any 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. Included in the policy should be a standardized protocol outlining expected standards and the process for addressing disruptive behavior issues, recommendations, follow-up plans, and actions to be taken in the face of individual resistance or refusal to comply. Prior to implementation, make sure all employees are familiar with the existence, purpose, and content of the policies and procedures. For the process to unfold, the organization needs to encourage its employees to report disruptive behaviors. The organization needs to address issues related to confidentiality, fear of retaliation, and common feelings that there is a double standard and that nothing ever gets done. Reporting mechanisms should be made easy and must be supported by the presence of 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 vehicles 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 with assigned responsibilities for addressing these issues. Besides maintaining confidentiality and reducing the risk of retaliation, one of the most crucial aspects of the reporting system is to give recognition and assurance that the complaints will be addressed and corresponding actions will be taken. Responses should be timely, appropriate, consistent, and provide necessary feedback and follow up (O’Daniel & Rosenstein, 2008). 

Taking action through appropriate intervention strategies is next. On one level, generic educational programs can do a lot to spread the message and teach basic communication skills. Appropriate topics should 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 flow. Another important strategy is to promote and provide competency training at all levels of the health care team. This is a key factor affecting trust and respect, which have a strong influence on team collaboration. Focused team training programs have been of particular value. Having a clinical champion or 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 through the voluntary interest and enthusiasm of other staff members. Co-champions may even be more effective. Some organizations have reported that having a nurse and physician (or other health care professional) go through a joint training program will help foster mutual cooperation and collaboration between the different disciplines. Follow-up and feedback bring closure to the process. It is important to let people know that their input is welcomed, follow-up actions will be taken, and appropriate feedback will be provided  (O’Daniel & Rosenstein, 2008).

Mutual Respect

Humble, gracious, polite, courteous, civil, considerate, well-mannered. If these words do not describe the interactions between the health care professionals at your hospital, you are, sadly, not alone. While a culture of disrespect is harmful on many levels, its effect on patient safety makes it a matter of national urgency, according to Lucian Leape, MD, of the Harvard School of Public Health and his esteemed colleagues, who authored a two-part exploration of disrespectful physician behavior in the journal Academic Medicine (Grissinger, 2015). 

Mutual respect is of the utmost importance among all members of the healthcare team and must be valued by each individual. In addition, all hierarchy must be eliminated because a healthcare system that is hierarchal in nature does not encourage collaborative practice. Hierarchy is also a barrier to communication. For example, some old-school male physicians may still think that the nurse (traditionally a position filled by women) should be subservient and make no contributions on a professional level (Kearney-Nunnery, 2016). 

In the classic work by Patterson, Grenny, McMillan, and Switzler (2002) Crucial Conversations: Tools for Talking When Stakes are High, they state that people cannot stay in a conversation if they do not have mutual respect. Mutual respect is the continuance condition of dialogue. If people perceive that others don’t respect them, the conversation immediately comes to a screeching 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 (Patterson et al., 2002).

Teamwork

Teamwork has been shown to provide benefits to health care providers, including reducing extra work and increasing job satisfaction. Characteristics have been identified in both sports and health care that may influence team success.  Examples include accountability, communication, leadership, discipline, coordination, having a clear purpose and having a strategy in place (Bosch & Mansell, 2015).

The literature reviewed shows that effective teams are characterized by common purpose and intent, trust, respect, and collaboration. Team members value familiarity over formality and watch out for each other to make sure mistakes are not made. Health care teams that do not trust, respect, and collaborate with one another are more likely to make a mistake that could negatively impact the safety of patients (O’Daniel & Rosenstein, 2008).

In the 2002 classic work entitled The Five Dysfunctions of a Team, Patrick Lencioni reveals the five dysfunctions that go to the very heart of why even the best teams often struggle.  He outlines a powerful model with actionable steps that can be used to overcome these five common hurdles and build cohesive, effective teams. Lencioni identifies the following dysfunctions (see Figure 1 below) as well as positive characteristics that may overcome each dysfunction:

Dysfunction 1- 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 one another’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 (Lencioni, 2002).

Dysfunction 2- Fear of Conflict- It is important to distinguish productive ideological conflict from destructive fighting and interpersonal politics.  The purpose is to produce the best possible solution in the shortest period of time. Teams that engage in healthy conflict:

• Have lively, interesting meetings.
• Extract and exploit the ideas of all team members.
• Solve real problems quickly.
• Minimize politics.
• Put critical topics on the table for discussion (Lencioni, 2002).

Dysfunction 3- Lack of Commitment- In the context of teams, commitment is a function of two things: clarity and buy-in.  Great teams make clear and timely decisions and move forward with complete buy-in from every member of the team, even those who voted against the decision. The two greatest causes of a lack of commitment is 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 (Lencioni, 2002).

Dysfunction 4- 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 (Lencioni, 2002).

Dysfunction 5- Inattention to Results- The ultimate dysfunction of a team is the tendency of members to care about something other than the collective goals of the group.  An unrelenting focus on specific objectives and clearly defined outcomes is a requirement 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 (Lencioni, 2002).

Figure 1: Patrick Lencioni’s Model of the Five Dysfunctions of a Team

(Lencioni, 2002)

Strategies and Examples to Improve Interdisciplinary Collaboration

TeamSTEPPS®

In 2005, the Agency for Healthcare Research and Quality collaborated with the U.S. Department of Defense to develop TeamSTEPPS®—Team Strategies and Tools to Enhance Performance and Patient Safety. This evidence-based patient safety toolkit addresses the leading causes of medical errors and helps organizations improve the quality, safety, and efficiency of health care delivery. TeamSTEPPS® is specifically designed as a resource for health care providers to improve patient safety through effective communication and teamwork skills (Health Research & Educational Trust, 2015). 

TeamSTEPPS® is based on a framework of four core competencies: communication, leadership, situation monitoring, and mutual support (see Figure 2 below). Many hospitals and care systems are using the TeamSTEPPS® framework to improve their culture, and consequently their patient safety. TeamSTEPPS® training has driven measurable quality improvement in various delivery areas (Health Research & Educational Trust, 2015). 

   

Figure 2. TeamSTEPPS® Framework and Competencies 

(Agency for Healthcare Research and Quality, 2014) 

• 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 common understandings of the team environment, apply strategies to monitor team members’ performance, maintain a shared mental model.
• Mutual support – anticipate other team members’ needs through accurate knowledge, shift workload to achieve balance during periods of high workload or stress. See Table 1 below for tools to facilitate each core competency (Health Research & Educational Trust, 2015).

There are three phases to 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).

Table 1. Teamwork Tools to Enhance Patient Safety

Tool	Brief Description
Communication
SBAR	A standardized technique for communicating critical information that requires immediate attention and action concerning a patient’s condition. SBAR stands for Situation, Background, Assessment and Recommendation/Request.
Call-out	A tactic used to communicate important or critical information. It informs all team members simultaneously during emergent situations and helps team members anticipate next steps.
Check-back	A strategy for closed-loop communication to ensure that information conveyed by the sender is understood by the receiver as intended.
Handoff	The transfer of information during transitions in care across the continuum. It provides an opportunity to ask questions, clarify and confirm. A specific tool for this is “I PASS THE BATON” which is designed to enhance the information exchange.
Leadership
Brief	A short session prior to the start of a procedure or event to share the plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, and anticipate outcomes and likely contingencies.
Huddle	Ad hoc meeting to re-establish situational awareness, reinforce plans already in place, and assess the need to adjust the plan.
Debrief	Informal information exchange session designed to improve team performance and effectiveness through lessons learned and reinforcement of positive behaviors.
Situation Monitoring
STEP	A tool for monitoring situations in the delivery of health care and useful in situation monitoring of the patient.  STEP stands for Status of the patient, Team members, Environment, Progress towards a goal.
Cross-monitoring	A harm error reduction strategy that involves: monitoring the actions of other team members, providing a safety net within the team, ensuring that mistakes or oversights are caught quickly and easily. “Watching each other’s back”.
I’M SAFE checklist	A checklist used during situation monitoring by each team member to assess his or her own safety status.  I’M SAFE stands for Illness, Medication, Stress, Alcohol and Drugs, Fatigue, Eating and Elimination.
Mutual Support
Two-challenge rule	Empowers all team members to “stop the line” if they sense or discover an essential safety breach.
CUS	An assertive statement used when a team member would like to “stop the line”. I am Concerned! I am Uncomfortable! This is a Safety Issue!
DESC script	An approach for managing and resolving conflict. DESC stands for Describe, Express, Suggest, Consequences.

(Health Research & Educational Trust, 2015)

Conclusion 

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

The essence of teamwork is that it is not a sum of the parts, but how those parts perceive their contributions toward the goal, work together, and exhibit fidelity to one another.  When clinical nurses and nurse managers dedicate themselves to collaborative relationships, the harmony that ensues is palpable.  Nurses can then excel at their work, and deliver on the ultimate and critical goal of high-value patient care (ANA/AONE, 2015). 

References

Agency for Healthcare Research and Quality (2014). About TeamSTEPPS®. TeamSTEPPS®: National implementation. Retrieved from http://teamstepps.ahrq.gov/about-2cl3.htm

American Nurses Association & American Organization of Nurses Executives (2015). ANA/AONE Principles for Collaborative Relationships between Clinical Nurses and Nurse Managers.  Retrieved from https://www.aonl.org/guiding-principles-relationships-among-nursing-and-support-services-clinical-setting

American Nurses Credentialing Center. (2019). Forces of magnetism. Retrieved from: https://www.nursingworld.org/organizational-programs/magnet/history/forces-of-magnetism/#13

Bosch, B., & Mansell, H. (2015). Interprofessional collaboration in health care: Lessons to be learned from competitive sports. Canadian Pharmacists Journal. 148(4), 176–179. doi:10.1177/1715163515588106. 

Grissinger, M. (2015). A compelling call to action to establish a culture of respect. Pharmacy and Therapeutics 40(8) p. 480-481.

Health Research & Educational Trust. (2015). Improving patient safety culture through teamwork and communication: TeamSTEPPS. Chicago, IL: Health Research & Educational Trust. Accessed at www.hpoe.org 

The Joint Commission. (2015). National patient safety goals effective January 1, 2015. (pp. 1-17) Retrieved from https://www.jointcommission.org/assets/1/6/2015_NPSG_HAP.pdf

Kearney-Nunnery, R. (2016). Advancing your career: Concepts of professional nursing (6th ed). Philadelphia, PA: F.A. Davis.

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

O’Daniel M., & Rosenstein, A. (2008).  Professional communication and team collaboration. In Patient safety and quality: An evidence-based handbook for nurses (p. 271-284). R.Hughes, (ED). Rockville, MD: Agency for Research and Quality.

Patterson, K., Grenny, J., McMillan, R., & Switzler, A. (2002). Crucial conversations: Tools for talking when the stakes are high. New York: McGraw-Hill.

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), p. 618–634.

Quality and Safety for Nurses (2019).  Graduate QSEN competencies. Retrieved from http://qsen.org/competencies/graduateksas/#teamwork_collaboration