Enhancing Communication

and Developing Collaboration Between

Healthcare Teams

Celeste Gray RN, MSN

Objectives

• Identify the current healthcare system and how lack of communication and collaboration is affecting the patient

• Define communication and collaboration in the healthcare system

• Identify barriers to communication and collaboration

• Describe ways communication and collaboration can assist in the development of effective teams for the safety of the patient

Today’s Healthcare Setting

• Communication, collaboration, and teamwork do not always occur in clinical settings

• Social, relational, and organizational structures contribute to communication failures

• Organizational structure is a large contributor to adverse clinical events and outcomes

• Priorities of patient care differs between members of the healthcare team

Today’s Healthcare System

• Involve numerous interfaces and patient handoffs among multiple healthcare workers with various training and education levels

• During a 4 day hospital stay a patient may interact with up to 50 different employees

Today’s Healthcare Setting

• More than 1/5th of patients hospitalized in the U.S. reported– Hospital system problems– Staff provides conflicting information– Staff unsure of which physician is in charge of their

care

Study of Physician and Nurse Disruptive Behaviors

Bridge the Gap

• Teach communication techniques and tools available for effective communication

• Build collaboration and effective teams through role clarity

• Review process so if there is a lack of communication and collaboration patient care is not affected

• Build a culture around collaboration

Definition of Communication

• The imparting or interchange of thoughts, opinions, or information by speech, writing, or signs

• 93% of communication is non-verbal which includes body language, attitude, and tone

• 7% are actual words said

What does Lack of Communication Cause?

• Faulty and incomplete exchange of information• Professionals ignore potential red flags and

clinical discrepancies• Creates situations where medical errors can

occur• These errors have the potential to cause severe

injury or unexpected patient death

Barriers to Effective Communication

• Health professionals tend to work autonomous• Efforts to improve health care safety and quality

are often jeopardized

Common Barriers

• Personal values and expectations • Personality differences • Hierarchy • Disruptive behavior • Culture and ethnicity • Generational differences • Gender • Historical inter-professional and

intra-professional rivalries• Differences in accountability,

payment, and rewards• Concerns regarding clinical

responsibility

• Differences in language and jargon

• Differences in schedules and professional routines

• Varying levels of preparation, qualifications, and status

• Differences in requirements, regulations, and norms of professional education

• Fears of diluted professional identity

• Complexity of care• Emphasis on rapid decision

making

Communication Styles

• Aggressive• Passive• Assertive

Aggressive Style• Communication Skills

– Closed minded– Poor listeners– Cant see others point of view– Interrupts/Monopolizes

conversation• Beliefs

– “Everyone should be like me”– “I am never wrong”

• Characteristics– Achieve goals at other’s expense– Bully– Patronizing and sarcastic

• Behaviors– Put down– Do not think they are wrong– Bossy– Overpowers– Know it all – Doesn’t show appreciation

• Feelings– Angry– Hostile– Frustrated– Impatient

• Nonverbal Cues– Point fingers– Frown– Glare– Loud tone rigid posture

• Verbal Cues– “You must”– “Just do it”– Verbally abusive

• Problem Solving Mechanisms– Must always win a argument– Operates in a win/lose paradigm

Passive Style• Communication Style

– Indirect– Always agrees– Doesn’t speak up– Hesitant

• Beliefs– “Don’t express true feelings”– Don’t make waves”– Don’t disagree”– “Other have more rights”

• Characteristics– Apologetic

• Behaviors– Avoid conflict– Asks permission unnecessarily– Complains instead of taking action– Have difficulty implementing plans

• Feelings– Powerlessness– Wonder why they do not get credit

for good work– Others are better

• Nonverbal Cues– Fidgets– Nods head often and smiles– No eye contact– Low volume

• Verbal Cues– Monotone voice

• Problem Solving Mechanisms– Avoid and ignore the problem– Withdraw from the situation

Assertive Style• Communication skills

– Effective, active listener– States limits/sets expectations– Does not judge– Considers other’s feelings

• Beliefs– Believes all are valuable– Handle all situations as best as

possible even if they do not win– All have rights and opinions

• Characteristics– Self aware– Trust themselves and others– Open and flexible– Proactive

• Behaviors– Fair/consistent– Action oriented

• Feelings– Enthusiastic– Even tempered– Positive

• Nonverbal Cues– Open and natural gestures– Direct eye contact– Relaxed– Vocal volume appropriate

• Verbal Cues– Use “I” statements– Ask for options

• Problem Solving Mechanisms– Negotiate, bargain and trade– Confronts problems as they happen– Do not let negative feelings build up

When Aggressive Style is Essential

• When a decision has to be made quickly• During emergencies• When you know you are right and that fact is

crucial

When Passive Style is Essential

• When an issue is minor• When the problem caused by conflict are greater

then the conflict itself• When emotions are running high and time is

needed to gain and regain perspective• When the other’s position is impossible to

change for all practical purposed (government policies)

Effective Communication

• Positive outcomes• Improved information flow• More effective interventions• Improved safety• Enhanced employee morale• Increased patient and family satisfaction• Decreased length of stay• Improved quality

Guidelines for Nurses

• Have I seen and assessed this patient myself before I call?

• Do I have at hand – The chart?– List of current meds, IV fluids,

and labs?– Most recent vital signs?– If reporting lab work, date and

time this test was done and results of previous tests for comparisons?

– Code status?• Have I read the most recent MD

progress notes and notes from the nurse who worked the shift ahead of me?

• Have I discussed this call with my charge nurse?

• When ready to call

– Remember to identify self, unit, patient, room number.

– Know the admitting diagnosis and date of admission.

– Briefly state the problem, what it is, when it happened or started, and how severe it is

• What do I expect to happen as a result of this call?

• Document whom you spoke to, time of call, and summary of conversation.

• Engage and treat physician with respect.

Standardized Communication Tools

• SBAR – Situation– Background– Assessment– Recommendation

SBAR

• Framework for communication between members of the healthcare team about the patient’s condition

• Easy to remember tool for framing all conversation especially critical requiring immediate attention and action.

• Easy and focused way to set expectations between members of the team for what will be communicated and how

• Develop desired critical thinking skills

Definition of Collaboration in Healthcare

• Health care professionals assuming complementary roles and cooperatively working together, sharing responsibility for problem solving and making decisions to formulate and carry out plans for patient care

Effective Teams

• Characterized by trust, respect, and working together for the good of the goal

Barriers to Fostering a Collaborative Team

Environment• Additional time• Perceived loss of autonomy• Lack of confidence or trust in decisions of others• Clashing perceptions• Territorialism• Lack of awareness of the education, knowledge,

and skills held by colleagues from other disciplines

Role Clarity and Work Alignment

• Create a knowledge-based, patient-centered approach to care delivery.

• Improve documentation and interdisciplinary communication.

• Sharpen critical thinking skills including new understandings of organizing and accomplishing work activities.

• Maximize use of resources through awareness

• Establish a rational framework for delegation and decisions that maximizes skill mix.

• Increase appreciation for the complexity of clinical care.

• Create of platform to engage the staff in implementing unit-specific responses to organizational initiatives.

Understanding Between Healthcare Workers

• Ongoing initiatives for the development of a cooperative agenda to benefit patient care

• Share at least one similar characteristic– A personalized desire to learn

• Share at least one value– To meet the needs of the patient

Successful Teamwork Model

• Open communication

• Non-punitive environment

• Clear direction

• Clear and known roles and tasks for team members

• Respectful atmosphere

• Shared responsibility for team success

• Appropriate balance of member participation for the task at hand

• Acknowledgment and processing of conflict

• Clear specifications regarding authority and accountability

• Clear and known decision making procedures

• Regular and routine communication and information sharing

• Enabling environment, including access to needed resources

• Mechanism to evaluate outcomes and adjust accordingly

Crew Resource Management (Aviation)

• CRM can be defined as a management system which makes optimum use of all available resources - equipment, procedures and people - to promote safety and enhance the efficiency of operations.

CRM in Aviation

• Team– Heavy emphasis on team training and team building

behaviors– Each member of the crew has specific responsibilities

for keeping the team intact and functioning so all important information is communicated in a timely and effective manner

– All members of the team were expected to play an active role in the decision making process

– Focused on the crucial roles and responsibilities of those who support the captain

CRM in Aviation

• Human factors– Aware of limitations of human performance– Teach to be acutely aware of fatigue and it effects on

performance and decision making– Restrictions on the use of alcohol and strategies to

optimize the use of caffeine for optimal sleep– The effects of life stressors on performance is openly

discussed• “are you ok to fly today”

CRM in Aviation

• Standardization– Standardized procedures, maneuvers, and actions

are ingrained in the culture– Everyone completes the task in the same manner– Teams can work together seamlessly and know

exactly what the other members are doing– If someone fails to follow the standard it is

investigated immediately

CRM Aviation

• Recurrent training and performance checking through simulation– Knowledge testing

• Computerized and oral testing

– Performance testing• Demonstration proficiency• Demonstrate how they work as a team when problem solving

abnormalities• Performance under observation helps manage the natural

anxiety that accompanies such an event

– Practice recurrent training and performance checking at a minimum every 12 months

CRM Aviation

• Checklists– Live and die by checklists– Provides another measure of standardization– Adhere to checklists consistently and without question– Checklists are the backbone of the airline safety

culture

Healthcare

• Hierarchy– Cultural road blocks to effective communication– Patients are in danger based on intense authority

gradients existing within the nurse-physician dyads– Healthcare relationships are characterized not by

open communication and team orientation but an emphasis on centralized power in decision making

Healthcare

• Missed meals– NL- stand for “No Lunch”– Cultured responded by offering compensation rather

then fix the core issues – This can become part of a healthcare worker’s

financial planning

Healthcare

• Fatigue– Research on the negative effects of fatigue on motor

and cognitive performance is well documented• Multiple 12 hour shifts• Heavy physical work• Demanding, repetitive mental work• Safety sensitive work• Work requiring vigilance

Healthcare

• Task load– Task saturation – Multitasking is reaching unmanageable levels

but demands precision and success

Healthcare

• Non-nursing functions– Required to take on tasks when other

departments are short• Adds to task saturation• Interrupts nursing thought process• Places patients at risk

Healthcare

• Distractions– “Critical regime

Healthcare

• Standardization– Frame of reference– Serves to mitigate the unexpected– Allows to predict behavior in both routine and

emergent circumstances

Healthcare

• Recurrent training and performance checklists– Staff are rarely are asked to go back to the classroom

setting to review policy and procedure– Yearly competency is often set up as a formality and

can be haphazard

Establishing a Culture to Support Communication and

Collaboration• Commitment needs to come from the top down and the

bottom up which makes a statement about the way the organization does business

• Behavioral Standards– Defects in communication that affect collaboration– Information exchange– Appreciation of roles and responsibility– Direct accountability for patient care

Establishing a Culture to Support Communication and

Collaboration• Develop and implement a standard set of

behavior policies and procedures– Policies should be the same for all disciplines and

service lines– Should become part of the medical staff bylaws with

signed agreements– Standardized protocol outlining expected standards

and the process for addressing disruptive behavior issues, recommendations, follow-up plans and action to be taken in the face of individual resistance of refusal to comply

Establishing a Culture to Support Communication and

Collaboration• Develop a process and encourage employees to

report disruptive behavior– Address issues related to confidentiality, fear of

retaliation, and the common feelings that there is a double standard and that nothing will get done

– Reporting methods should be made easy and must be supported by a non-punitive environment

– Ideally address the issue in real time

Reporting Continued

• Appropriate avenues for reporting– Reporting the incident to a superior– Incident reports– Complaint or suggestion box– Reporting directly to a task force or interdisciplinary

committee with assigned responsibilities for addressing the issues

• Maintain confidentiality and reduce risk of retaliation• Provide recognition and assurance that the complaint will

be addressed and actions will be taken• Response should be timely, appropriate, consistent, and

provide necessary feedback and follow-up

Establishing a Culture to Support Communication and

Collaboration• Taking actions through appropriate intervention

strategies– Education

• Team dynamics• Communication skills• Phone etiquette• Assertiveness training• Diversity training• Conflict management• Stress management

Intervention Strategies Continued

– Focus sessions and counseling– Competency

• All levels of the healthcare team

Establishing a Culture to Support Communication and

Collaboration• Focused team trainings programs

– Training on fostering an environment of trust and respect

– Accountability– Situational awareness– Open communication– Assertiveness– Shared decision making– Feedback – Interdisciplinary CRM training

Establishing a Culture to Support Communication and

Collaboration• Identifying clinical champions or early adopters

promotes the importance of appropriate behaviors, communication, and team collaboration– Champions can come from executive teams or

through voluntary interests– Co-champions where physicians and nurses go

through training together– Simulation– Committees

Conclusion

• Effective clinical practice can’t focus on technical only but must include human factors

• Good 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 foster team collaboration

Questions

References• Hughes, RG. Patient Safety and Quality: Evidenced Based Handbook for Nurses. Agency for Healthcare

Research and Quality (US). 2008 (Apr.).• Koloroutis, M. Relationship Based Care: A Model for Transforming Practice. Creative Heath Management

Team (US) 2012. (Jun).• Patterson, K. Grenny, J. McMillan, R., Switzler, A. Crucial Conversation Tools for Talking When Stakes are High.

(US) 2012.• Saxton, R., Hines, T., Enriquez, M. (2009). The negative impact of the nurse-physician disruptive behavior on

patient safety: a review in literature. Journal of Patient Safety, 5(3), 180-183.• Sculli, G.L., Sine, D.M. ; Souring to Success: Taking Crew Resources Management from the Cockpit to the

Nursing Unit. (US) 2011• Vazirani, S., Hays, R.D., Shapiro, M., Cowan, M. (2005). Effect of a multidisciplinary intervention on

communication and collaboration among physicians and nurses. American Journal of Critical Care, 14(1), 71-77.