A 55-year-old white male presented at the emergency department (ED) complaining of shortness of breath and chest pain. He was morbidly obese (BMI of 36.8) and his medical history indicated a prior diagnosis of hypertension and three prior experiences of less severe but similar symptoms. Although prescribed with metoprolol (Lopressor) (100 mg daily), the patient admitted that he had not been taking the medication at all. He also had sleep apnea and used a CPAP machine.
The patient worked at a very high-stress occupation and was in the middle of a bitter divorce, with custody and access to his young children a major bone of contention. His family history included heart disease, including a same-age cousin, who has died from sudden heart attack a few months ago. The patient was admitted and remained in hospital for several days until his condition was stabilized and diagnostic tests came back. Tests showed he was pre-diabetic, with ventricular dilation and cardiomyopathy. He was dehydrated due to inadequate cardio function and had minor renal damage.
A healthcare team which was created to address his health issues included: a cardiologist, an endocrinologist to monitor patient’s diabetes, a nephrologist to monitor kidney damage, a dietician to work on weight loss and diabetes management and a physical therapist to assist in developing an appropriate exercise regimen. Those team members were enhanced by the many supporting team members, including phlebotomists, imaging specialists, physician assistants, and the nursing staff.
While such an extended healthcare team may once have been unusual, in the current healthcare environment and particularly with patients with multiple comorbidities, teamwork across specialists is a frequent requirement. This paper addresses issues and best practices in working on such diverse healthcare teams and educating staff members on appropriate teamwork in such teams. The paper concludes with a summary of appropriate research priorities regarding healthcare teamwork relevant to nurse leaders.
Best Practices in Healthcare Teamwork and Collaboration
Nurse leaders and nurse managers are crucial parts of healthcare teams and often serve as the nexus for intrateam communications. Grumbaugh and Flynn (2018) noted that having effective nurse managers to help coordinate healthcare teams has led to reduced numbers of adverse health events, better nursing care, and overall improved patient outcomes. A crucial part of effective teamwork in a hospital environment is the willingness of team members to assist other team members in mutual support, a process known as team backup (Grumbaugh & Flynn, 2018).
Such backup was formally identified as early as 2006 by the Agency for Healthcare Research and Quality (AHRQ) with the release of their report Team Strategies and Tools to Enhance Performance and Patient Safety (Team STEPPS); that report noted that effective healthcare teamwork was associated with improved patient outcomes (Grumbaugh & Flynn). Being an effective nurse leader in teamwork situations requires the ability to manage conflict and provide effective communication among team members.
Grumbaugh and Flynn noted in particular that nurses and nurse managers frequently avoid conflicts rather than resolve them, possibly due to lack of conflict management training. This approach is ineffective and may lead to unhealthy communication, increased staff stress, and poorer patient care. Instead, rather than avoidance of conflict, nurse leaders need to use any alternative approach including competing, accommodating, and/or collaborating, all of which have been found as effective conflict management strategies (Grumbaugh & Flynn,2018).
Effective healthcare teamwork requires more than simply having all participants desire to work together. Gittell et al. (2015) further noted that specific organizational teamwork measures are needed in order to understand issues that exist in current healthcare teams and to determine appropriate alterations in how teams are coordinated and operate. Gittell et al. (2015) identified three key relational aspects that were crucial to effective healthcare teams: having a shared goal, sharing knowledge, and having mutual respect.
These involve an environmental change in healthcare organizations and have been identified as elements that support improved interprofessional collaboration (Regan, Laschinger & Wong, 2016). A study of the influence of organizational aspects found that when healthcare organizations which provided nurses with structural empowerment, authentic leadership, and professional nursing environments experienced have enhanced interprofessional collaboration and teamwork (Regan et al.).
In this context, structural empowerment refers to an organization that provides staff with the ability to conduct their work in meaningful ways, that support opportunities for growth within the organization, and that gives supportive peer and supervisor feedback (Regan et al.). Authentic leadership refers to having leaders who are true to their values and strengths and that provide their staff with the power to do the same in a positive work environment (Regan et al.)
A professional work environment is one that complies with the American Nurses Association (ANA) hallmarks for support for a professional nursing practice; these hallmarks include, among others, a philosophy that emphasizes quality, safety, interdisciplinary collaboration and accountability; that recognizes contributions nurses make to patient care and outcomes; that promotes executive level nurse leaders; that empowers nurses to participate in clinical decision-making; and that promotes nurse growth and development (Regan et al.). An appropriate action plan for nurses in any healthcare organization would be one that actively lobbies organizational management to attain the ANA hallmarks for professional nursing practice and to improve those hallmarks that currently exist.
Educating Nurses on Teamwork Practices
The American Academy of Nursing on Policy (AANP) released a white paper that specifically addressed the importance of educating nurses on effective interprofessional teamwork, noting that extensive studies have demonstrated its value in improved patient care and outcomes and stating that such coordination is a foundation for improving overall patient care quality (Camicia et al., 2013). Importantly, the AANP white paper stated that ‘nurses are central to coordinating the patient experience, targeting both cost efficiencies and improved care outcomes for diverse patient groups’ (Camicia et al, 2013, p. 493).
Literature supports the importance of nurse leaders understanding two key aspects for interprofessional collaboration and teamwork: effective conflict management and effective team communication (Gittell et al., 2015; Regan et al. 2016). Current best-practices encourages and supports the need for interprofessional training to address problems such as obesity and its common comorbidities, as exemplified by the example case described at the beginning of this report (Dietz et al., 2015).
With obesity as one example, the Edmonton obesity staging system noted that appropriate treatment for obesity beyond Stage 0 (i.e., no obesity-related risk factors such as blood pressure, serum lipids, normal fasting glucose levels, no physical symptoms or wellbeing impairments) requires significant interprofessional healthcare team that can include lifestyle interventions, pharmacological treatments, management of comorbidities such as sleep apnea, osteoarthritis, hypertension, type 2 diabetes, cardiovascular issues, etc. (Dietz et al., 2015). Understanding and respecting other specialties is a critical part of establishing effective team collaboration, which can require practical experience. For example, Roberts et al. (2016) suggested that more effective healthcare teamwork skills could be developed using design thinking, a paradigm pulled from industry.
This process includes giving team members practice by exposing them to new experiences, potentially via cross-training in other specialties enough to develop an empathy for those other team members; by encouraging a process that actively encourages input from team members (such as nurses) who might otherwise be ignored, and by reframing problems to increase limitations to encourage creativity and innovation (Roberts et al., 2016). A further set of skills for effective interprofessional teams include team leadership, mutual performance monitoring, mutual assistance, adaptability, and having a team orientation (Weller, Boyd, and Cumin, 2014). These skills are ones that could and should be included in nurse training and provided in continuing educational programs for working nurses.
Needed Future Research on Teamwork in Healthcare
Based on the literature reviewed, several areas of nursing leadership research could be conducted to improve healthcare teamwork and collaboration skills. For example, research in whether training in the design thinking modality using the specific suggestions from Roberts et al. (2016) could determine if that approach to learning teamwork skills was effective. Additional research was also suggested by Camicia et al. (2013), who noted that research should be done on how nurses and nurse leaders overcome barriers in healthcare team settings.
Grumbaugh and Flynn (2018) noted that a key issue for nurses and nurse managers in healthcare teams is the ability to communicate effectively and manage conflict in positive ways. One area that needs further research thus includes studies of how such communication skills and conflict management techniques can be most effectively taught to nurses both in nurses training environments and as part of continuing education for working nurses. Gittell et al. (2015) further identified the importance of organizational changes to improve interprofessional teamwork.
Thus, research that identified which specific organizational changes significantly improved healthcare team effectiveness would be important. A critical lack in many healthcare teams is effective information sharing with as many as one-quarter of communications even in critical situations such as the operating room resulting in failed information transfer (Weller et al., 2014).
Handoffs, particularly across departments such as from an operating room staff to medical ward nurses, often lacked key information such as allergies and problems within the operation performed (Weller et al., 2014). Conducting research on various strategies to teach effective communications techniques thus could improve handoff and other interprofessional communication barriers.