Interprofessional Collaboration
Overview of this chapter
This chapter emphasizes interprofessional collaboration and the core competencies around it, such as teamwork, as essential competencies that keep patients safe and improve health outcomes through effective communication and respect for others. It will describe the roles of various members of the interdisciplinary health care team. Nurses play different roles and responsibilities in different health care settings and work as a team member when providing patient care. As nurses, it is important to uses the resources appropriately and limited health care resources are allocated wisely, and consumers receive the health care they need. The roles of the nurse continuity of care between and among health care setting will be emphasized . This chapter includes information on Teamwork, TeamSTEPS and collaboration among healthcare team.
Learning Objectives
At the end of this chapter, the learner will:
1. Describe the roles of various members of the interdisciplinary health care team.
2. Discuss the use of various resources in the delivery of healthcare.
3. Discuss the effective use of health care resources.
4. Describe the role of the nurse in ensuring continuity of care between and among health care settings.
5. Collaborate with the interprofessional healthcare team in diverse healthcare settings.
Interprofessional Collaboration
Collaboration and teamwork is vital in healthcare setting. The Interprofessional Education Collaborative (IPEC), a conglomeration of various health professions programs and entities puts forward “Core Competencies for Interprofessional Collaborative Practice“. These core competencies reflect the vision that interprofessional collaborative practice is key to safe, high-quality, accessible, equitable, person/client-centered care and enhanced population health outcomes desired by all. This competency set is aimed at preparing future health professionals to engage in lifelong learning and collaboration to improve both person/client care and population health outcomes ( IPEC, 2023):
IPEC Core Competencies
Inteprofessional
- Values and Ethics: Work with team members to maintain a climate of shared values, ethical conduct, and mutual respect.
- Roles and Responsibilities: Use the knowledge of one’s own role and team members’ expertise to address individual and population health outcomes.
- Communication: Communicate in a responsive, responsible, respectful, and compassionate manner with team members.
- Teams and Teamwork: Apply values and principles of the science of teamwork to adapt one’sown role in a variety of team settings.
Due to the complexity of the US healthcare system, all health professions must commit to collaborative practice (NAM, 2000). Effective teams encourage members to be curious about processes, ask questions, and learn about, from and with each other to prevent errors and improve patient outcomes (AHRQ, n.d.; IPEC 2016; WHO, n.d.). Teamwork, Values and ethics, knowledge of the team members roles and responsibilities, communication are elements of collaboration. These are essential components that drive the delivery of high-quality patient care. The interconnected nature of medical, emotional, and social aspects of health demands a multifaceted approach, which can only be effectively achieved through the concerted efforts of a diverse team of healthcare professionals. The rationale for teamwork and collaboration are:
- Enhanced Patient Outcomes :Effective teamwork and collaboration in healthcare lead to improved patient outcomes. When healthcare professionals from various disciplines work together, they bring their unique perspectives and expertise to the table. This holistic approach ensures comprehensive patient care, addressing all aspects of a patient’s health and well-being. Collaborative efforts have been shown to reduce medical errors, improve patient satisfaction, and enhance the overall quality of care (Reeves et al., 2017).
- Efficient Use of Resources :Collaboration among healthcare professionals facilitates the efficient use of resources. By sharing knowledge and coordinating care, the team can avoid unnecessary duplication of tests and procedures, thereby reducing healthcare costs. Additionally, it allows for better management of healthcare resources, ensuring that patients receive the right care at the right time (Baker et al., 2005).
- Improved Communication: Communication is a critical factor in healthcare. Interprofessional collaboration fosters open communication channels among team members, which is vital for the accurate exchange of information. Clear and effective communication helps in early identification of potential issues, timely intervention, and the development of effective care plans. This ultimately leads to a safer and more efficient healthcare system (O’Daniel & Rosenstein, 2008).
- Professional Development :Working in a collaborative environment encourages continuous learning and professional development. Healthcare professionals can learn from each other, gain new insights, and enhance their skills. This not only benefits the individual professionals but also contributes to the overall advancement of the healthcare field (Barr et al., 2005).
- Patient-Centered Care: Teamwork and collaboration are the cornerstones of patient-centered care. When healthcare providers work together, they can develop care plans that are tailored to the individual needs of patients. This approach ensures that patients are treated with dignity, respect, and compassion, which is fundamental to delivering high-quality healthcare (Institute of Medicine, 2001).
What is Interprofessional Collaboration? Listen to this podcast to learn some more: Interprofessional Collaboration
VALUES AND ETHICS FOR INTERPROFESSIONAL PRACTICE
Components of IPEC’s Values/Ethics for Interprofessional Practice Competency[3]
- Place interests of clients and populations at the center of interprofessional health care delivery and population health programs and policies, with the goal of promoting health and health equity across the life span.
- Respect the dignity and privacy of clients while maintaining confidentiality in the delivery of team-based care.
- Embrace the cultural diversity and individual differences that characterize clients, populations, and the health team.
- Respect the unique cultures, values, roles/responsibilities, and expertise of other health professions and the impact these factors can have on health outcomes.
- Work in cooperation with those who receive care, those who provide care, and others who contribute to or support the delivery of prevention and health services and programs.
- Develop a trusting relationship with clients, families, and other team members.
- Demonstrate high standards of ethical conduct and quality of care in contributions to team-based care.
- Manage ethical dilemmas specific to interprofessional client/population-centered care situations.
- Act with honesty and integrity in relationships with clients, families, communities, and other team members.
- Maintain competence in one’s own profession appropriate to scope of practice.
ROLES AND RESPONSIBILILITES OF HEALTH CARE PROFESSIONALS
Components of IPEC’s Roles/Responsibilities Competency[2]
- Communicate one’s roles and responsibilities clearly to clients, families, community members, and other professionals.
- Recognize one’s limitations in skills, knowledge, and abilities.
- Engage with diverse professionals who complement one’s own professional expertise, as well as associated resources, to develop strategies to meet specific health and health care needs of clients and populations.
- Explain the roles and responsibilities of other providers and the manner in which the team works together to provide care, promote health, and prevent disease.
- Use the full scope of knowledge, skills, and abilities of professionals from health and other fields to provide care that is safe, timely, efficient, effective, and equitable.
- Communicate with team members to clarify each member’s responsibility in executing components of a treatment plan or public health intervention.
- Forge interdependent relationships with other professions within and outside of the health system to improve care and advance learning.
- Engage in continuous professional and interprofessional development to enhance team performance and collaboration.
- Use unique and complementary abilities of all members of the team to optimize health and client care.
- Describe how professionals in health and other fields can collaborate and integrate clinical care and public health interventions to optimize population health.
INTERPROFESSIONAL COMMUNICATION
Components of IPEC’s Interprofessional Communication Competency[4]
- Choose effective communication tools and techniques, including information systems and communication technologies, to facilitate discussions and interactions that enhance team function.
- Communicate information with clients, families, community members, and health team members in a form that is understandable, avoiding discipline-specific terminology when possible.
- Express one’s knowledge and opinions to team members involved in client care and population health improvement with confidence, clarity, and respect, working to ensure common understanding of information, treatment, care decisions, and population health programs and policies.
- Listen actively and encourage ideas and opinions of other team members.
- Give timely, sensitive, constructive feedback to others about their performance on the team, responding respectfully as a team member to feedback from others.
- Use respectful language appropriate for a given difficult situation, crucial conversation, or conflict.
- Recognize how one’s uniqueness (experience level, expertise, culture, power, and hierarchy within the health care team) contributes to effective communication, conflict resolution, and positive interprofessional working relationships.
- Communicate the importance of teamwork in client-centered care and population health programs and policies.
TEAMS AND TEAMWORK
Components of IPEC’s Teams and Teamwork Competency[2]
- Describe the process of team development and the roles and practices of effective teams.
- Develop consensus on the ethical principles to guide all aspects of teamwork.
- Engage health and other professionals in shared client-centered and population-focused problem-solving.
- Integrate the knowledge and experience of health and other professions to inform health and care decisions, while respecting client and community values and priorities/preferences for care.
- Apply leadership practices that support collaborative practice and team effectiveness.
- Engage self and others to constructively manage disagreements about values, roles, goals, and actions that arise among health and other professionals and with clients, families, and community members.
- Share accountability with other professions, clients, and communities for outcomes relevant to prevention and health care.
- Reflect on individual and team performance for individual, as well as team, performance improvement.
- Use process improvement to increase effectiveness of interprofessional teamwork and team-based services, programs, and policies.
- Use available evidence to inform effective teamwork and team-based practices.
- Perform effectively on teams and in different team roles in a variety of settings.
Spotlight:
The necessity of teamwork and collaboration in healthcare cannot be overstated. These elements are integral to improving patient outcomes, optimizing resource use, enhancing communication, fostering professional development, and providing patient-centered care. By embracing a collaborative approach, healthcare professionals can create a more effective and compassionate healthcare system.
Clinical Application: The nurse in an Interprofessional healthcare environment
In a bustling medical-surgical unit of a large metropolitan hospital, Registered Nurse (RN) Sarah is starting the morning shift. The unit is known for its high patient turnover and the need for seamless teamwork and collaboration among healthcare professionals to ensure optimal patient outcomes.
The Team:
•Sarah (RN); Dr. Ahmed (Surgeon); Dr. Chen (Physician), Tom (Pharmacist), Emily (Physical Therapist), Lisa (Social Worker)
The Patient:
Mr. Johnson, a 65-year-old male, was admitted two days ago for a complex abdominal surgery. Post-surgery, he has developed complications including pain management issues, difficulty mobilizing, and concerns about his discharge plan as he lives alone.
Knowledge Check:
Morning Huddle:
At the beginning of her shift, Sarah participates in the morning huddle with the interprofessional team. Each member provides updates on their patients, and together they prioritize tasks for the day.
I. Roles and responsibilities of health care professionals
Nurses communicate with several individuals during a typical shift. For example, during inpatient care, nurses may communicate with patients and their family members; pharmacists and pharmacy technicians; providers from different specialties; physical, speech, and occupational therapists; dietary aides; respiratory therapists; chaplains; social workers; case managers; nursing supervisors, charge nurses, and other staff nurses; assistive personnel; nursing students; nursing instructors; security guards; laboratory personnel; radiology and ultrasound technicians; and surgical team members. Providing holistic, quality, safe, and effective care means every team member taking care of patients must work collaboratively and understand the knowledge, skills, and scope of practice of the other team members.
The table below provides examples of the roles and responsibilities of common health care team members that nurses frequently work with when providing patient care. To fully understand the roles and responsibilities of the multiple members of the complex health care delivery system, it is beneficial to spend time shadowing those within these roles.
| Member | Role/Responsibilities |
|---|---|
| Assistive Personnel (e.g., certified nursing assistants [CNA], patient-care technicians [PCT], certified medical assistants [CMA], certified medication aides, and home health aides) | Work under the direct supervision of the RN. |
| Licensed Practical/Vocational Nurses (LPN/VN) | Assist the RN by performing routine, basic nursing care with predictable outcomes. |
| Registered Nurses (RN) | Use the nursing process to assess, diagnose, identify expected outcomes, plan and implement interventions, and evaluate care according to the Nurse Practice Act of the state they are employed. |
| Charge Nurses or Nursing Supervisors | Supervise members of the nursing team and overall patient care on the unit (or organization) to ensure quality, safe care is delivered. |
| Directors of Nursing (DON), Chief Nursing Officer (CNO), or Vice President of Patient Services | Ensure federal and state regulations and standards are being followed and are accountable for all aspects of patient care. |
| Clinical Nurse Specialist (CNS) | Practice in a variety of health care environments and participate in mentoring other nurses, case management, research, designing and conducting quality improvement programs, and serving as educators and consultants. |
| Nurse Practitioners (NP) or Advanced Practice Registered Nurses (APRN) | Work in a variety of settings and complete physical examinations, diagnose and treat common acute illness, manage chronic illness, order laboratory and diagnostic tests, prescribe medications and other therapies, provide health teaching and supportive counseling with an emphasis on prevention of illness and health maintenance, and refer clients to other health professionals and specialists as needed. NPs have advanced knowledge with a graduate degree and national certification. |
| Certified Registered Nurse Anesthetists (CRNA) | Administer anesthesia and related care before, during, and after surgical, therapeutic, diagnostic, and obstetrical procedures, as well as provide airway management during medical emergencies. |
| Certified Nurse Midwives (CNM) | Provide gynecological exams, family planning guidance, prenatal care, management of low-risk labor and delivery, and neonatal care. |
| Medical Doctors (MD) | Licensed providers who diagnose, treat, and direct medical care. There are many types of physician specialists such as surgeons, pulmonologists, neurologists, cardiologists, nephrologists, pediatricians, and ophthalmologists. |
| Physician Assistants (PA) | Work under the direct supervision of a medical doctor as licensed and certified professionals following protocols based on the state in which they practice. |
| Doctors of Osteopathy (DO) | Licensed providers similar to medical physicians but with different educational preparation and licensing exams. They provide care, prescribe, and can perform surgeries. |
| Dieticians | Assess, plan, implement, and evaluate interventions related to specific dietary needs of clients, including regular or therapeutic diets. Formulate diets for clients with dysphagia or other physical disorders and provide dietary education such as diabetes education. |
| Physical Therapists (PT) | Develop and implement a plan of care as a licensed professional for clients with dysfunctional physical abilities, including joints, strength, mobility, gait, balance, and coordination. |
| Occupational Therapists (OT) | Plan, provide, and evaluate care for clients with dysfunction affecting their independence and ability to complete activities of daily living (ADLs). Assist clients in using adaptive devices to reach optimal levels of functioning and provide home safety assessments. |
| Speech Therapists (ST) | Develop and initiate a plan of care for clients diagnosed with communication and swallowing disorders. |
| Respiratory Therapists (RT) | Specialize in treating clients with respiratory disorders or conditions in collaboration with providers. Provide treatments such as CPAP, BiPAP, respiratory treatments and medications like aerosol nebulizers, chest physiotherapy, and postural drainage. They also intubate clients, assist with bronchoscopies, manage mechanical ventilation, and perform pulmonary function tests. |
| Social Workers (SW) | Provide a liaison between the community and the health care setting to ensure continuity of care after discharge. Assist clients with establishing community resources, health insurance, and advance directives. |
| Psychologists and Psychiatrists | Provide mental health services to clients in both acute and long-term settings. As physician specialists, psychiatrists prescribe medications and perform other medical treatments for mental health disorders. Psychologists focus on counseling. |
| Nurse Case Managers or Discharge Planners | Ensure clients are provided with effective and efficient medical care and services, during inpatient care and post-discharge, while also managing the cost of these services. |
The coordination and delivery of safe, quality patient care demands reliable teamwork and collaboration across the organizational and community boundaries. Clients often have multiple visits across multiple providers working in different organizations. Communication failures between health care settings, departments, and team members is the leading cause of patient harm. The health care system is becoming increasingly complex requiring collaboration among diverse health care team members.
The goal of good interprofessional collaboration is improved patient outcomes, as well as increased job satisfaction of health care team professionals. Patients receiving care with poor teamwork are almost five times as likely to experience complications or death. Hospitals in which staff report higher levels of teamwork have lower rates of workplace injuries and illness, fewer incidents of workplace harassment and violence, and lower turnover. Valuing and understanding the roles of team members are important steps toward establishing good interprofessional teamwork.
Exercises: Knowledge check
Spotlight: The Roles of Nurses-Contrubitions to the Inteprofessional Healthcare Team
A. Resource Stewardship
Resource Stewardship is one of the Standards of Professional Performance established by the American Nursing Association (ANA). is defined as using appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, financially responsible, and used judiciously. See the following box for competencies associated with the ANA’s Resource Stewardship Standard of Professional Performance.
B. Case Management
Nurses are tasked with daily case management activities and allocating appropriate resources to their clients. Two common types of case management that staff nurses provide are educating clients about using appropriate levels of care and encouraging the use of cost-effective health care team members.
Several levels of care are available to clients for their health care services:
- Emergency department care has specialized providers and high-level diagnostics and should be reserved for immediate and potentially life-threatening needs.
- Urgent care is an elevated level of care above an outpatient visit, yet below the needs of an emergency visit. Nurses should refer patients to this setting if they have a health need that needs attention within the next 24 hours but is not life-threatening.
- Outpatient health settings provide health maintenance for chronic disease or treatment of nonurgent acute conditions. They also provide preventative services like well-baby checks and immunizations. In the outpatient setting, the nurse recognizes the patient’s time with a provider is limited, so the majority of a nurse’s time is often spent providing patient education, answering questions, and coordinating care.
- Inpatient and acute care typically occurs in a hospital setting where skilled nursing, diagnostic tests, and medical treatments are required. Nursing goals in these settings are to address immediate health concerns, stabilize the client, and prepare them for discharge. Most inpatient stays are 72 hours or less, so nurses must provide efficient care that includes adequate patient education regarding follow-up care after discharge.
- Assisted living refers to licensed facilities that provide safe living accommodations and three meals daily. Residents receive assistance with medications and ADLs and may receive general nursing care.
- Skilled nursing facilities, commonly referred to as “nursing homes” or “long-term care facilities,” are licensed facilities that provide 24-hour licensed nursing services. Residents may require total assistance with ADLs
- Home health refers to services provided in a client’s home that may include nursing, home health aide, physical therapy (PT), occupational therapy (OT), and speech therapy.
- Hospice offers palliative and supportive services providing physical, psychological, social, and spiritual care for dying clients and their families. Services may be provided in the client’s home or an inpatient setting. Hospice may include nursing, home health aide, social worker, chaplain, PT, OT, ST, nutritional therapy, and volunteer services.
- Telehealth is a fairly new and expanding health delivery model. Telehealth is a form of an outpatient health service where the patient and member of the health care team are able to connect remotely using telephone calls or video conferencing on a computer with an Internet connection. Devices may be provided to monitor vital signs and other health indicators. Telehealth enhances client access to multiple providers without the burden of travel. Telehealth has become an important resource in rural communities, especially due to social distancing required by the COVID-19 pandemic.
Nurses can also address the economic pressures within the health care system by utilizing and advocating for cost-effective care by providers on the health care team. In this manner, limited health care resources are allocated wisely, and consumers receive the health care they need. For example, many Nurse Practitioners (NPs) and Physician Assistants (PAs) function as primary providers in outpatient settings and provide preventative services, treat self-limited acute medical conditions, and manage chronic disease. NPs and PAs are trained to refer clients for specialized care when indicated. Some NPs and PAs work in specialized inpatient areas and serve as the primary point of contact during a patient’s hospital stay. Nurses recognize the time of specialty physicians is limited and unnecessary referrals can be costly to the client. By using and advocating for the wise use of these health care human resources, nurses can help reduce the overall cost of health care.
According to ANA (2021), registered nurses routinely coordinate with members of patients’ health care teams every day in the course of delivering health care services to patients, whether in acute care, long-term care, private practice, or other settings. Patient-centered care coordination is a core professional standard for all registered nurses and is central to nurses’ longtime practice of providing holistic care to patients—incorporating interventions from a variety of disciplines into traditional health care approaches. For these reasons, the ANA supports the promotion and involvement of registered nurses in the development of future care coordination models. Specifically, the ANA believes that registered nurses must be:
- Recognized as essential to successful care coordination in the nation’s health care delivery system. This recognition must come from policymakers, health care professionals, and payers.
- Appropriately compensated for the services they provide to patients and families. There must be payment parity across all qualified health professionals for the scope of services they provide in delivering high-value care coordination.
- Included in the design and endorsement, and use of rigorously tested care coordination measures, which are central to the domain of nursing. The contributions of registered nurses performing care coordination services must be defined, measured, and reported to inform and ensure appropriate financial and systemic incentives for the professional care coordination role.
Competencies of ANA’s Resource Stewardship Standard of Professional Performance
- Partners with the health care consumer and other stakeholders to identify care needs and necessary resources to achieve desired outcomes.
- Collaborates with the health care consumer and other stakeholders to assess costs, availability, risks, and benefits in decisions about care.
- Secures appropriate resources to address needs across the health care continuum.
- Advocates for equitable resources that support and enhance nursing practice and health outcomes.
- Integrates connected health technologies into practice to promote positive interactions between health care consumers and care providers.
- Uses organizational and community resources to implement interprofessional plans.
- Addresses discriminatory health care practices and the adverse impact on allocation of resources.
CLinical Application
Registered Nurse Emma is assigned to care for a 64-year-old patient readmitted with heart failure (HF). Emma recognizes the patient’s name during shift report as the reporting nurse comments how this patient was a “frequent flyer,” and was just discharged last week. The reporting nurse spends little time describing the patient’s actual condition and focuses comments on how the patient “might as well put their name plaque on the door” because of frequent admissions. Emma does agree that the patient has been readmitted very frequently with symptoms of heart failure but is concerned by the dismissive comments by her peer. She is determined to spend time with this patient on this admission and find out more about their home environment, support system, and self-care.
Emma engages in a conversation with the client about his dietary habits at home. He reports that his wife passed away one year ago from breast cancer, and he has been preparing his own meals since that time by using easy-to-prepare and cheap foods. Canned soups, boxed meals, and chips are common staples in his diet. Through Emma’s conversation with the patient, she can see that the patient needs dietary instruction and further education about monitoring his fluid retention with daily weights. He seems engaged in exploring different food preparations and was unaware that foods could exacerbate his heart failure. When Emma asked if he had been taught about this on previous admissions, he stated that no one took the time to talk with him about his home situation. He reports that he received pamphlets but never really took the time to read them because the print was so small. Emma reflects on how preventative education opportunities were missed and increased costs were incurred by the patient and the health care organization as a result.
Reflective Questions
- How do the frequent readmissions affect the client’s health care costs and the hospital’s reimbursement levels by Medicare and private insurance companies?
- What additional nursing interventions might help prevent future frequent readmissions and reduce costs?
II. Effective Teamwork
Nurses work in teams with patients, other nurses, and many disciplines to communicate pertinent information that enhances patient care and health outcomes. Developing effective teams is critical for providing health care that is patient-centered, safe, timely,
effective, efficient, and equitable.
Nurses collaborate with the interprofessional team not only by assigning and coordinating tasks, but also by promoting solid teamwork in a positive environment. A nursing leader, such as a charge nurse, identifies gaps in workflow, recognizes when task overload is occurring, and promotes the adaptability of the team to respond to evolving patient conditions. Qualities of a successful team are described in the following box.
Qualities of A Successful Team
- Promote a respectful atmosphere
- Define clear roles and responsibilities for team members
- Regularly and routinely share information
- Encourage open communication
- Implement a culture of safety
- Provide clear directions
- Share responsibility for team success
- Balance team member participation based on the current situation
- Acknowledge and manage conflict
- Enforce accountability among all team members
- Communicate the decision-making process
- Facilitate access to needed resources
- Evaluate team outcomes and adjust as needed
Spotlight; Teams and Teamwork
What is the psychology of team work and how hard can it be? Listen to this podcast: Teamwork and Collaboration
Who is on the team? Here is one more podcast: Who is on the Team
TeamSTEPPS® is an evidence-based framework used to optimize team performance across the health care system. It is a mnemonic standing for Team Strategies and Tools to Enhance Performance and Patient Safety. The Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD) developed the TeamSTEPPS® framework as a national initiative to improve patient safety by improving teamwork skills and communication.
View this video about the TeamSTEPPS® framework
TeamSTEPPS® is based on establishing team structure and four teamwork skills: communication, leadership, situation monitoring, and mutual support. See below for an image of the TeamSTEPPS® framework followed by a description of each TeamSTEPPS® skill. The components of this model are described in the following sections.
Team Structure
A nursing leader establishes team structure by assigning or identifying team members’ roles and responsibilities, holding team members accountable, and including clients and families as part of the team.
A. Communication
Communication is the first skill of the TeamSTEPPS® framework. As previously discussed, it is defined as a “structured process by which information is clearly and accurately exchanged among team members.” All team members should use these skills to ensure accurate interprofessional communication:
- Provide brief, clear, specific, and timely information to other team members.
- Seek information from all available sources.
- Use ISBARR and handoff techniques to communicate effectively with team members.
- Use closed-loop communication to verify information is communicated, understood, and completed.
- Document appropriately to facilitate continuity of care across interprofessional team members.
B. Leadership
Leadership is the second skill of the TeamSTEPPS® framework. As previously discussed, it is defined as the “ability to maximize the activities of team members by ensuring that team actions are understood, changes in information are shared, and team members have the necessary resources.” An example of a nursing team leader in an inpatient setting is the charge nurse.
Effective team leaders demonstrate the following responsibilities:
- Organize the team.
- Identify and articulate clear goals (i.e., share the plan).
- Assign tasks and responsibilities.
- Monitor and modify the plan and communicate changes.
- Review the team’s performance and provide feedback when needed.
- Manage and allocate resources.
- Facilitate information sharing.
- Encourage team members to assist one another.
- Facilitate conflict resolution in a learning environment.
- Model effective teamwork.
Three major leadership tasks include sharing a plan, monitoring and modifying the plan according to situations that occur, and reviewing team performance. Tools to perform these tasks are discussed below:
Sharing the Plan
Nursing team leaders identify and articulate clear goals to the team at the start of the shift during inpatient care using a “brief.” The brief is a short session to share a plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, and anticipate outcomes and contingencies.
Monitoring and Modifying the Plan
Throughout the shift, it is often necessary for the nurse leader to modify the initial plan as patient situations change on the unit. A huddle is a brief meeting before and/or during a shift to establish situational awareness, reinforce plans already in place, and adjust the teamwork plan as needed. Read more about situational awareness in the “Situation Monitoring” subsection below.
Reviewing the Team’s Performance
When a significant or emergent event occurs during a shift, such as a “code,” it is important to later review the team’s performance and reflect on lessons learned by holding a “debrief” session. A debrief is an informal information exchange session designed to improve team performance and effectiveness through reinforcement of positive behaviors and reflection on lessons learned.
C. Situation Monitoring
Situation monitoring is the third skill of the TeamSTEPPS® framework and defined as the “process of actively scanning and assessing situational elements to gain information or understanding, or to maintain awareness to support team functioning.” Situation monitoring refers to the process of continually scanning and assessing the situation to gain and maintain an understanding of what is going on around you. Situation awareness refers to a team member knowing what is going on around them. The team leader creates a shared mental model to ensure all team members have situation awareness and know what is going on as situations evolve. The STEP tool is used by team leaders to assist with situation monitoring.
The STEP tool is a situation monitoring tool used to know what is going on with you, your patients, your team, and your environment. STEP stands for Status of the patients, Team members, Environment, and Progress toward goal. See an illustration of STEP in Figure 8.3. The components of the STEP tool are described in the following box.
Cross Monitoring
As the STEP tool is implemented, the team leader continues to cross monitor to reduce the incidence of errors. Cross monitoring includes the following:
- Monitoring the actions of other team members.
- Providing a safety net within the team.
- Ensuring that mistakes or oversights are caught quickly and easily.
- Supporting each other as needed.
Read an example of a nursing team leader performing situation monitoring using the STEP tool in the following box.
Exercises: Application in Practice
Example of Situation Monitoring
Two emergent situations occur simultaneously on a busy medical-surgical hospital unit as one patient codes and another develops a postoperative hemorrhage.
- The charge nurse is performing situation monitoring by continually scanning and assessing the status of all patients on the unit and directing additional assistance where it is needed.
- Each nursing team member maintains situation awareness by being aware of what is happening on the unit, in addition to caring for the patients they have been assigned.
- The charge nurse creates a shared mental model by ensuring all team members are aware of their evolving responsibilities as the situation changes.
- The charge nurse directs additional assistance to the emergent patients while also ensuring appropriate coverage for the other patients on the unit to ensure all patients receive safe and effective care.
For example, as the “code” is called, the charge nurse directs two additional nurses and two additional assistive personnel to assist with the emergent patients while the other nurses and assistive personnel are directed to “cover” the remaining patients, answer call lights, and assist patients to the bathroom to prevent falls. Additionally, the charge nurse is aware that after performing a few rounds of CPR for the coding patient, the assistive personnel must be switched with another team member to maintain effective chest compressions. As the situation progresses, the charge nurse evaluates the status of all patients and makes adjustments to the plan as needed.
- Share an emergency situation or an experience that you have experienced.
- Explain how you or the team leader conducted situational monitoring.
D. Mutual Support
Task Assistance
Helping other team members with tasks builds a strong team. Task assistance includes the following components:
- Team members protect each other from work-overload situations.
- Effective teams place all offers and requests for assistance in the context of patient safety.
- Team members foster a climate where it is expected that assistance will be actively sought and offered.
Feedback
Feedback is provided to a team member for the purpose of improving team performance. Effective feedback should follow these parameters:
- Timely: Provided soon after the target behavior has occurred.
- Respectful: Focused on behaviors, not personal attributes.
- Specific: Related to a specific task or behavior that requires correction or improvement.
- Directed towards improvement: Suggestions are made for future improvement.
- Considerate: Team members’ feelings should be considered and privacy provided. Negative information should be delivered with fairness and respect.
Advocating for Safety with Assertive Statements
When a team member perceives a potential patient safety concern, they should assertively communicate with the decision-maker to protect patient safety. This strategy holds true for ALL team members, no matter their position within the hierarchy of the health care environment. The message should be communicated to the decision-maker in a firm and respectful manner using the following steps:
- Make an opening.
- State the concern.
- State the problem (real or perceived).
- Offer a solution.
Reach agreement on next steps.
Exercises: Application of Using Assertive Statements to Promote Patient Safety
Example
1. A nurse notices that a team member did not properly wash their hands during patient care.
2. Practice: Assertive Statements to Promote Patient Safety
- You notice that a team member did not lower the bed to the lowest position after patient care.
- Share your feedback to your team member using assertive statements to promote patient safety.
CUS Assertive Statements
During emergent situations, when stress levels are high or when situations are charged with emotion, the decision-maker may not “hear” the message being communicated, even when the two-challenge rule is implemented. It is helpful for agencies to establish assertive statements that are well-recognized by all staff as implementation of the two-challenge rule. These assertive statements are referred to as the CUS mnemonic: “I am Concerned – I am Uncomfortable – This is a Safety issue!” See Figure 8.4 for an illustration of CUS assertive statements.
Figure 8.4 CUS Assertive Statements
Using these scripted messages may effectively catch the attention of the decision-maker. However, if the safety issue still isn’t addressed after the second statement or the use of “CUS” assertive statements, the team member should take a stronger course of action and utilize the agency’s chain of command. For the CUS assertive statements to be effective within an agency, administrators must support a culture of safety and emphasize the importance of these initiatives to promote patient safety.
Role play : Assertive Statement Example
A nurse observes a new physician resident preparing to insert a central line at a patient’s bedside. The nurse notes the resident has inadvertently contaminated the right sterile glove prior to insertion.
- Pair up with another student and role play as the nurse and Dr. Smith.
- Share how you supported the culture of effective safety.
Nurse: “Dr. Smith, I noticed that you contaminated your sterile gloves when preparing the sterile field for central line insertion. I will get a new set of sterile gloves for you.”
Dr. Smith: (Ignores nurse and continues procedure.)
Nurse: “Dr. Smith, please pause the procedure. I noticed that you contaminated your right sterile glove by touching outside the sterile field. I will get a new set of sterile gloves for you.”
Dr. Smith: “My gloves are fine.” (Prepares to initiate insertion.)
Nurse: “Dr. Smith – I am concerned! I am uncomfortable! This is a safety issue!”
Dr. Smith: (Stops procedure, looks up, and listens to the nurse.) “I’ll wait for that second pair of gloves.”
Knowledge Check:
III. Application in Practice
Exercises 1 & 2
- Reflective Activity
- View the following YouTube video illustrating an interdisciplinary care conference as a patient’s plan of care is designed and implemented.
Interprofessional Professionalism Collaborative
Reflective Questions:
a. As you watch the video, notice how the professionals from different health disciplines communicate and interact with each other to formulate the plan of care for a patient and how the care is continued through multidisciplinary involvement.
b. Assess interprofessional collaborative practice of the health care team using the following PDF: Interprofessional Professionalism Assessment Tool
2.
Exercises
IV. Reflections
Key Takeaways
Type your key takeaways here.
- First
- Second
V. Recommended Resources
Agency for Health Care Research and Quality, Care Coordination Measures Atlas – The Atlas includes measures of patient and caregiver experiences with care coordination, as well as experiences of health care professionals and health system managers.
Creating a healthy work environment (HWE) : https://www.aacn.org/nursing-excellence/healthy-work-environments
Communicating with Health Care Team Members: https://med.libretexts.org/Bookshelves/Nursing/Nursing_Fundamentals_(OpenRN)/02%3A_Communication/2.04%3A_Communicating_with_Health_Care_Team_Members
Interprofessional Professionalism Collaborative. (2018, August 15). IPC case scenario for Mr. Jones part I. [Video]. YouTube. All rights reserved. https://youtu.be/woHaclEtLFw ↵
Visit the TeamSTEPPS® Instructor Manual: Specialty Scenarios for multiple AHRQ scenarios requiring application of TeamSTEPPS® to patient scenarios.
Attributions and References
In conclusion, **References**
– Baker, D. P., Day, R., & Salas, E. (2005). Teamwork as an essential component of high-reliability organizations. *Health Services Research, 41*(4 Pt 2), 1576-1598.
– Barr, H., Koppel, I., Reeves, S., Hammick, M., & Freeth, D. (2005). *Effective Interprofessional Education: Argument, Assumption, and Evidence.* Wiley-Blackwell.
– Institute of Medicine. (2001). *Crossing the Quality Chasm: A New Health System for the 21st Century.* National Academies Press.
– O’Daniel, M., & Rosenstein, A. H. (2008). Professional communication and team collaboration. In R. G. Hughes (Ed.), *Patient Safety and Quality: An Evidence-Based Handbook for Nurses.* Agency for Healthcare Research and Quality (US).
– Reeves, S., Lewin, S., Espin, S., & Zwarenstein, M. (2017). *Interprofessional Teamwork for Health and Social Care.* Wiley-Blackwell.
Ernstmeyer & Christman (Eds.) (OpenRN) via source content that was edited to the style and standards of the open education resources.
- World Health Organization. (2010). Framework for action on interprofessional education & collaborative practice. https://www.who.int/publications/i/item/framework-for-action-on-interprofessional-education-collaborative-practice ↵
- AHRQ. (2015, July). TeamSTEPPS: National implementation research/evidence base. https://www.ahrq.gov/teamstepps/evidence-base/safety-culture-improvement.html ↵
- National Academies of Sciences, Engineering, and Medicine. (2021). The future of nursing 2020-2030: Charting a path to achieve health equity. The National Academies Press. https://doi.org/10.17226/25982 ↵
4. Interprofessional Professionalism Collaborative. (2019). IPA tool kit. http://www.interprofessionalprofessionalism.org/toolkit.html ↵
5. American Association of Critical-Care Nurses. (n.d.). Healthy work environments. https://www.aacn.org/nursing-excellence/healthy-work-environments
6. American Association of Critical-Care Nurses. (2005, May). AACN standards for establishing and sustaining healthy work environments: A journey to excellence. American Journal of Critical Care, 14(3), p.187-197. DOI: 10.4037/ajcc2005.14.3.187
7. Ulrich, B., Barden, C., Cassidy, L., & Varn-Davis, N. (2019). Critical Care Nurse Work Environments 2018: Findings and Implications. Critical Care Nurse, 30(2). http://dx.doi.org/10.4037/ccn2019605
8.National Academy of Medicine. (2011). The Future of Nursing: Leading Change, Advancing Health.Washington, DC: National Academies Press. http://www.nationalacademies .org/hmd/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx
9.American Association of Colleges of Nursing. (2020, September). Fact sheet: Nursing shortage. https://www.aacnnursing.org/Portals/42/News/Factsheets/Nursing-Shortage-Factsheet.pdf
10. American Nurses Association (2015). Code of Ethics for Nursing with Interpretative Statements. https://www.nursingworld.org/coe-view-only.
11. Interprofessional Education Collaborative (2016). Core competencies for interprofessional collaborative practice: 2016 update. Interprofessional Education Collaborative. https://ipec.memberclicks.net/assets/2016-Update.pdf
12. Institute for Healthcare Improvement. (2019). About us: Mission and vision. http://www.ihi.org/about/Pages/default.aspx
13. Kowalski, K. (2015). Building teams through communication and partnerships. In P. S. Yoder-Wise’s P. S. Leading and Managing in Nursing (6th ed.) Elsevier.
14.Makary, M. A. & Daniel, M. (2016). Medical error – the third leading cause of death in the US. BMJ, BMJ 2016;353:i2139. https://www.bmj.com/content/353/bmj.i2139
15.McKnight H, Moore SM. (2022). Nursing shared governance. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK549862/
16.National League for Nursing. (2010). Outcomes and competencies for graduates of practical/vocational, diploma, associate degree, baccalaureate, masters’, practice doctorate, and research doctorate programs in nursing. National League for Nursing.
17.Speakman, E., Tagliareni, E., Sherburne, A., & Sicks, S. (2015). Guide to Effective Interprofessional Education Experiences in Nursing Education. Washington, DC: National League for Nursing. http://www.nln.org/docs/default-source/default-document-library/interprofessional-education-and-collaborative-practice-toolkit1.pdf
18.Scott, B. A. (2009). Thinking as a nurse. IUniverse.
19. The Joint Commission. (2016, June 20). Bullying has no place in health care. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-24-bullying-has-no-place-in-health-care/#.Y3O6EezMIrl
20. World Health Organization. (2010). Framework for Action on Interprofessional Education & Collaborative Practice. Geneva: World Health Organization. http://apps.who.int/iris/bitstream/handle/10665/70185/WHO_HRH_HPN_10.3_eng.pdf;jsessionid=FAFFA800C273367D929912AE0ABF8323?sequence=1
Attributions:
Centre for Interprofessional Education at the University of Toronto.- Interprofessional Collaboration and Teamwork and Podcasts
