Week 9: Teamwork and Collaboration

Overview of this chapter

This chapter 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. This chapter will describe the role of the nurse continuity of care between and among health care settings. Collaboration and teamwork is vital in healthcare setting. This chapter includes information on Teamwork, TeamSTEPPS  and collaboration among healthcare team. 

Introduction

Research shows that a healthy work environment can lead to more engaged nurses, decreased burnout, lower turnover and better patient care (American Association of Critical-Care Nurses, n.d.). 

“It is important to create work environments in which nurses have confidence they will be heard, and actions will be taken to resolve unsafe conditions” (Ulrich et al., 2019, p. 81).

This chapter emphasizes collaboration and teamwork as essential skills that keep patients safe and improve health outcomes through effective communication and respect for others. 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.).  Additionally, healthy work environments have been shown to positively impact staff and patient outcomes (Ulrich et. al 2019).

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.

Table 8.1 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.

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.

A. Resource Stewardship

Resource Stewardship is one of the Standards of Professional Performance established by the American Nursing Association (ANA). Resource stewardship 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:

1. 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.
2. 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.
3. 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.

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 by not only 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

 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.

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.

1. Share an emergency situation or an experience that you have experienced.
2. Explain how you or the team leader conducted situational monitoring.

D. Mutual Support

Mutual support is the fourth skill of the TeamSTEPPS® framework and defined as the “ability to anticipate and support team members’ needs through accurate knowledge about their responsibilities and workload.” Mutual support includes providing task assistance, giving feedback, and advocating for patient safety by using assertive statements to correct a safety concern. Managing conflict is also a component of supporting team members’ needs.

 

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.

Feedback is provided immediately in a private area after the team member left the patient room: “I noticed you didn’t wash your hands when you entered the patient’s room. Can you help me understand why that didn’t occur?” (Wait for an answer.)

“Performing hand hygiene is essential for protecting our patients from infection. It is also hospital policy and we are audited for compliance to this policy. Let me know if you have any questions and I will check back with you later in the shift.”

(Monitor the team member for appropriate hand hygiene for the remainder of the shift.)

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.

1. Pair up with another student and role play as the nurse and Dr. Smith.
2. 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.”

III. Application in Practice

IV. Reflections

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

Ernstmeyer & Christman (Eds.) (OpenRN) via source content that was edited to the style and standards of the open education resources.

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