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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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?
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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.