Allen Tanner MAC,MDiv,CS,CAAP,CPE
Definition of Communication:
Webster’s Dictionary defines communication as “the imparting or interchange of thoughts, opinions, or information by speech, writing, or signs.” It is important to consider that communication is not just verbal in form. One study states that 93 percent of communication is more affected by body language, attitude, and tone, leaving only 7 percent of the meaning and intent based on the actual words said. Whereas the spoken words contain the crucial content, their meaning can be influenced by the style of delivery, which includes the way speakers stand, speak, and look at a person. However, critical information is often transmitted via handwritten notes, e-mails, or text messages, which can lead to serious consequences if there is miscommunication.
Definition of Healthcare Collaboration:
Collaboration in health care is defined as 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. Collaboration between physicians, nurses, and other health care professionals increases team members ‘awareness of each others’ type of knowledge and skills, leading to continued improvement in decision making.
Effective teams are characterized by trust, respect, and collaboration. I am a great proponent of teamwork. Teamwork, I believe, is endemic to a system in which all employees are working for the good of a goal, who have a common aim, and who work together to achieve that aim. When considering a teamwork model in health care, an interdisciplinary approach should be applied. Unlike a multidisciplinary approach, in which each team member is responsible only for the activities related to his or her own discipline and formulates separate goals for the patient, an interdisciplinary approach coalesces a joint effort on behalf of the patient with a common goal from all disciplines involved in the care plan. The pooling of specialized services leads to integrated interventions. The plans of care takes into account the multiple assessments and treatment regimens, and it packages these services to create an individualized care program that best addresses the needs of the patient. The patient finds that communication is easier with the cohesive team, rather than with numerous professionals who do not know what others are doing to manage the patient. Below in “Table One,” I have compiled what I believe are a few of the components found in a successful teamwork model.
It is important for me to point out to you at this time that fostering a team collaboration environment may have hurdles to overcome such as:
Additional time
Perceived loss of autonomy
Lack of confidence or trust in decisions of others
Clashing perceptions
Territorialism
However, most of these hurdles can be overcome with an open attitude and feelings of mutual respect and trust. It will be through this improved teamwork and communication that improved clinical effectiveness and job satisfaction will emerge.
Table One: Components of Successful Teamwork:
Open communication
Non - Punitive environment
Clear direction
Clear and known roles and processes for team members
Respectful atmosphere
Shared responsibility for team success
Appropriate balance of member participation for the goal at hand
Acknowledgment and processing of conflict
Clear specifications regarding authority and accountability
Clear and known decision-making procedures
Regular and routine communication and information sharing
Enabling environment, including access to needed resources
Mechanism to evaluate outcomes and adjust accordingly
It is no surprise that communication, collaboration, and teamwork do not always occur in clinical settings. It is also no surprise that many health care workers are use to poor communication and teamwork, as a result of a culture of low expectations that has developed in many health care settings. This culture, in which health care workers have come to expect faulty and incomplete exchange of information, leads to errors because even conscientious professionals tend to ignore potential red flags and clinical discrepancies. They view these warning signals as indicators of routine repetitions of poor communication rather than unusual, worrisome indicators.
Positive Outcomes of Effective Communication:
Although “poor communication” can lead to tragic consequences, on the contrary, “effective communication” can lead to the following positive outcomes:
Improved information flow
More effective interventions
Improved safety
Enhanced employee morale
Increased patient and family satisfaction
Decreased lengths of stay
Implementing systems to facilitate team communication can substantially improve quality. Effective communication among staff encourages effective teamwork and promotes continuity and clarity within the patient care team. At its best, good communication encourages collaboration, fosters teamwork, and helps prevent errors.
Barriers to Effective Communication:
Health professionals tend to work autonomously, even though they may speak of being part of a team. Efforts to improve health care delivery, safety, and quality are often jeopardized by the communication and collaboration barriers that exist between clinical staff. Although every organization is unique, the barriers to effective communication that organizations face have some common themes. In “Table Two” below I have indicated some of those common barriers to inter-professional collaboration.
Table Two:
Common Barriers to Inter-professional
Communication and Collaboration:
Personal values and expectations
Personality differences
Hierarchy
Disruptive behavior
Culture and ethnicity
Generational differences
Gender
Historical inter-professional and intra-professional rivalries
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
Differences in accountability, payment, and rewards
Concerns regarding clinical responsibility
Complexity of care
Emphasis on rapid decision-making
The barriers indicated in above can occur within disciplines, most notably between physicians and residents, surgeons and anesthesiologists, and nurses, nurse managers, and case managers. However, most often the barriers manifest between nurses and physicians. Even though doctors and nurses interact numerous times a day, they often have different perceptions of their roles and responsibilities as to patient needs, and thus different goals for patient care. One barrier compounding this issue is that because the United States is one of the most ethnically and culturally diverse countries in the world, many clinicians come from a variety of cultural backgrounds. In all interactions, cultural differences can exacerbate communication problems. For example, in some cultures, individuals refrain from being assertive or challenging opinions openly. As a result, it is very difficult for nurses from such cultures to speak up if they see something wrong. In cultures such as these, nurses may communicate their concern in very indirect ways. Culture barriers can also hinder nonverbal communication. For example, some cultures ascribe specific meaning to eye contact, certain facial expressions, touch, tone of voice, and nods of the head.
Issues around gender differences in communication styles, values, and expectations are common in all workplace situations. In the health care industry, where most physicians are male and most nurses are female, communication problems are further accentuated by gender differences. Another common barrier to effective communication and collaboration is hierarchies. Communication failures in the medical setting arise at times from what is referred to as vertical hierarchical differences; this is a concern with upward influence, role conflict, and ambiguity and struggles with inter-personal and intra-personal power and conflict. Communication is likely to be distorted or withheld in situations where there are hierarchical differences between two communicators, particularly when one person is concerned about appearing incompetent, does not want to offend the other, or perceives that the other is not open to communication. Many times this is seen between physicians and nurses or between physicians and case managers. In health care environments characterized by a hierarchical culture, physicians are at the top of that hierarchy. Consequently, they may feel that the environment is collaborative and that communication is open while nurses and other direct care staff perceive communication problems. Hierarchy differences can come into play and diminish the collaborative interactions necessary to ensure that the proper treatments are delivered appropriately. When hierarchy differences exist, people on the lower end of the hierarchy tend to be uncomfortable speaking up about problems or concerns. Intimidating behavior by individuals at the top of a hierarchy can hinder communication and give the impression that the individual is unapproachable. When one person is concerned about appearing incompetent, does not want to offend the other, or perceives that the other is not open to communication. In health care environments characterized by a hierarchical culture, physicians are at the top of that hierarchy. Consequently, they may feel that the environment is collaborative and that communication is open while nurses and other direct care staff perceive communication problems. Hierarchy differences can come into play and diminish the collaborative interactions necessary to ensure that the proper treatments are delivered appropriately. When hierarchy differences exist, people on the lower end of the hierarchy tend to be uncomfortable speaking up about problems or concerns. Intimidating behavior by individuals at the top of a hierarchy can hinder communication and give the impression that the individual is unapproachable.
Staff who witness poor performance in their peers may be hesitant to speak up because of fear of retaliation or the impression that speaking up will not do any good.
Relationships between the individuals providing patient care can have a powerful influence on how and even if important information is communicated. I have seen delays in patient care and recurring problems from unresolved disputes are that were often the by-product of physician-nurse or physician-case manager disagreements. Then question is how common is the trend in which nurses are either reluctant or refuse to call physicians, even in the face of a deteriorating status in patient care. Reasons for this may include intimidation, fear of getting into a confrontational or antagonistic discussion, lack of confidentiality, fear of retaliation, and the fact that nothing ever seems to change. Many of these issues have to deal more with personality and communication style. The major concern about disruptive behaviors is how frequently they occur and the potential negative impact they can have on patient care.
It is time that leaders in both medicine and nursing have an ongoing initiative for the development of a cooperative rather than a competitive agenda to benefit patient care. It is my opinion that a powerful incentive for greater teamwork among professionals is created by directing attention to the areas where changes are likely to result in measurable improvements for the patients they serve together, rather than concentrating on what, on the surface, seem to be irreconcilable professional differences. Think about it for a moment, I think we can agree that it is a fact that most health professionals have at least one characteristic in common, a personal desire to learn, and that they have at least one shared value, to meet the needs of their patients or clients. This is a good place to start.
Known Benefits of Communication and Team Collaboration:
Because of the complexity of medical care, coupled with the inherent limitations of human performance, it is critically important that clinicians have standardized communication tools and create an environment in which individuals can speak up and express concerns. When a team needs to communicate complex information in a short period of time, it is helpful to use structured communication techniques to ensure accuracy. Structured communication techniques can serve the same purpose that clinical practice guidelines do in assisting practitioners to make decisions and take action.
Healthcare Professionals because they are involved in settings where there is a huge variability in circumstances, need to adapt processes quickly, with a quickly changing knowledge base.
Healthcare Professionals must use expert judgment in dynamic settings. The adoption of standardized tools and behaviors is a very effective strategy in enhancing teamwork and reducing risks.
Doctors and nurses often have different communication styles in part due to training. Nurses are taught to be more descriptive of clinical situations, whereas physicians learn to be very concise. Standardized communication tools are very effective in bridging this difference in communication styles.
Michael Leonard, physician coordinator of clinical informatics at Kaiser Permanente, along with colleagues, developed a technique called SBAR (Situation-Background-Assessment-Recommendation.)This technique has been implemented widely at health systems such as Kaiser Permanente. The SBAR technique provides a framework for communication between members of the health care team about a patient’s condition. SBAR is an easy-to-remember tool used to create mechanisms useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action. It allows for an easy and focused way to set expectations between members of the team for what will be communicated and how, which is essential for information transfer and cohesive teamwork. Not only is there familiarity in how people communicate, but the SBAR structure helps develop desired critical-thinking skills. The person initiating the communication knows that before they pick up the telephone, they need to provide an assessment of the problem and what they think an appropriate solution is. Their conclusion may not ultimately be the answer, but there is clearly value in defining the situation. *Table Five, Guidelines for communicating with Physicians Using the SBAR Process explains how to carry out the SBAR technique in detail. The guidelines use the physician team member as the example; however, they can be adapted for use with all other health professionals.
**Table Five SBAR (Situation, Background, Assessment, Recommendation)
SBAR – a technique for communicating critical information that requires immediate attention and action concerning a patient’s condition
Situation – What is going on with the patient? “I am calling about Mrs. Joseph in room 251. Chief complaint is shortness of breath of new onset.”
Background – What is the clinical background or context? “Patient is a 62-year-old female post-op day one from abdominal surgery. No prior history of cardiac or lung disease.”
Assessment – What do I think the problem is? “Breath sounds are decreased on the right side with acknowledgment of pain. Would like to rule out pneumothorax.”
Recommendation – What would I do to correct it? “I feel strongly the patient should be assessed now. Are you available to come in?”
[Note: Kaiser Permanente, SBAR (Situation, Background, Assessment, Recommendation) tool, 2002. Source for version in this table: Institute for Healthcare Improvement. Guidelines for communicating with physicians using the SBAR process. http://www.ihi.org/IHI/Topics/PatientSafety /SafetyGeneral/ Tools/SBARTechniq ueforCommunicationASituationalBriefing Model.htm. Accessed Nov. 18, 2004.]
**STICC (Situation Task Intent Concern Calibrate) is another type of structured briefing protocol the following five steps are involved:
Situation: Here's what I think we face.
Task: Here's what I think we should do.
Intent: Here's why.
Concern: Here's what we should keep our eye on.
Calibrate: Talk to me. Tell me if you don't understand, can't do it, or see something I do not.
We Must Establish a Culture To Support Communication and Team Collaboration:
Effective teams are characterized by common purpose and intent, trust, respect, and collaboration. Team members value familiarity over formality and watch out for each other to make sure mistakes are not made. Health care teams that do not trust, respect, and collaborate with one another are more likely to make a mistake that could negatively impact the quality of patient care.
One of the first crucial steps is organizational commitment and willingness to address the situation. Commitment needs to come from the top down and bottom up, making a statement about the way the organization does business. The rallying point should be around behavioral standards and their relationship to patient care. Addressing defects in communication that affect collaboration, information exchange, appreciation of roles and responsibilities, and direct accountability for patient care are key components of any communication and team building program. Clinical and administrative leaders must set the tone by establishing and adhering to behavioral standards that support agreed-upon code of conduct practices backed by a non-punitive culture and zero-tolerance policy.
The next step in the process is recognition and self-awareness. Organizations must be able to assess the prevalence, context, and impact of behaviors to identify potential opportunities for improvement. Doing an internal assessment will help pinpoint the seriousness of the situation and provide clues to areas that need to be addressed. Assessment information can be gained from formal methods such as incident reports, survey tools, focus groups, department meetings, task forces or committees, direct observation, suggestion boxes, and hot lines. Informal methods such as casual meetings and gossip can also provide valuable surface information and should be evaluated more deeply as to the source, relevance, and significance of the events to determine next steps. In many organizations there are still remnants of reluctance to address the issue head on for fear of antagonizing a prominent surgeon or staff member.
Creating opportunities for different groups to just get together is a highly effective strategy for enhancing collaboration and communication. These group interactions can be either formal or informal. Encouraging open dialogue, collaborative rounds, implementing pre-op and post-op team briefings, and creating interdisciplinary committees or task forces that discuss problem areas frequently provides an upfront solution that reduces the likelihood of disruptive events.
Developing and implementing communication and behavior standards is vital. These standards need to be consistent and universally applied. These standards should become a part of staff competencies with signed agreements to abide by these standards.
Taking action though appropriate intervention strategies is next. On one level, generic educational programs can do a lot to spread the message and teach basic skills necessary to promote effective communication. Appropriate topics should include sessions on team dynamics, communication skills, phone etiquette, assertiveness training, diversity training, conflict management, stress management, and any other courses necessary to foster more effective team functioning and communication flow. Courses should be offered to all staff and employees at the organization: physicians, physicians in training, nurses, nursing students, and all other staff who have patient contact or play a role in the delivery of patient care. For individuals who have consistently exhibited disruptive behavior, education may need to be supported by more focused sessions and specific counseling. I cannot stress enough the importance of promoting and assuring competency training at all levels of the health care team. This is a key factor affecting trust and respect, which have such a strong influence on team collaboration.
Having a clinical champion or early adopter who actively promotes the importance of appropriate behavior, communication, and team collaboration can be an extremely valuable asset. Champions can come from the executive ranks or through the voluntary interest and enthusiasm of other staff members. Co-champions may be even more effective. It may be beneficial having a nurse and physicians (or other health care professional) go through a joint training program together which will help foster mutual cooperation and collaboration between the different disciplines. Follow up and feedback bring closure to the process. It is important to let people know that their input is welcomed, follow-up actions will be taken, and appropriate feedback will be provided.
Conclusions:
Effective clinical practice must not focus only on technological system issues, but also on the human factor. I have attempted to show in this presentation, that good communication encourages collaboration and helps prevent errors. It is important for health care organizations to anticipate possible situations for poor communication and be diligent about offering programs and outlets to help foster team collaboration. By addressing this issue, health care organizations have an opportunity to greatly enhance their clinical outcomes.
