CHAPTER 5

OBJECTIVES

Upon completion of this chapter, the reader should be able to:

1. Discuss the purpose of a health care team.

2. Review the process of communication.

3. Review the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

4. Discuss the stages of group process and common team member roles.

5. Identify elements of the Myers-Briggs Type Indicator.

6. Explore crew resource management.

7. Discuss organizational communication.

8. Discuss how to overcome communication barriers.

9. Discuss groupthink.

of the Interdisciplinary Team

themselves accountable (p. 45).” On health care teams, the purpose is to meet patient care needs. On some teams, such as a nursing policy and procedure team, all members may have similar backgrounds and abilities. Other teams may be developed with interdisciplinary members who have a variety of skills and talents, to provide different perspectives and ideas on how to solve problems.

Everyone on an interdisciplinary team is trained in his or her specialty and looks at care delivery with a different focus, e.g., as nurses, physicians, social workers, dieticians, or case managers. Some- times having so many viewpoints can be diffi cult, though, especially if a single decision is needed and everyone has varying opinions.

To get the work of an organization completed, multiple formal and informal teams or groups may develop. Formal teams or groups may include a temporary ad hoc group that meets to accomplish a specifi c purpose, such as preparing for accredita- tion by the Joint Commission. Another formal team may be a permanent standing group or committee that meets regularly to accomplish organizational objectives, such as the Intensive Care Committee.

Informal teams may also evolve in organiza- tions. Shortell and Kaluzny (2006) state that the importance of informal workgroup structure and group processes has been recognized for many years. The Hawthorne experiments firmly estab- lished the proposition that an individual’s per- formance is determined in large part by informal As a new nurse, you are making the day’s assignments

for a 34-bed medical–surgical unit. Working with you today will be another two registered nurses, two licensed practical nurses, and one nursing assistant. You gradu- ated only a year ago and you were recently promoted to the role of charge nurse. Today, one of the licensed practical nurses and the nursing assistant are challenging your patient care assignments, saying you do not have enough experience to make a fair assignment. They are trying to get the two registered nurses to side with them. It appears that the two registered nurses often work together, as do the two licensed practical nurses. You know you made the best assignment given the staff available, yet you are won- dering if there is a better solution.

What would be the best way to address their concerns?

How can you work with your team to ensure fair patient assignments?

I

n today’s health care environment, great demands are placed on each health care pro- fessional to provide the best quality of care effi ciently, safely, and cost-effectively to optimize patient care outcomes. Many administrators and nurse managers recognize that effective inter- professional communication and collaboration through teamwork is needed to create a safe patient care environment. Collaboration and team- work among staff nurses and other disciplines in the health care setting is so critical to optimizing patient care safety and outcomes that it is a priority for most health care administrators, directors, and managers (Amos, Hu, & Herrick, 2005). This chap- ter discusses the key factors that build a successful nursing team. It also discusses the group process and ways in which a nurse can communicate on effective teams. Finally, it discusses organizational communication.

Teams and

Communication

Katzenbach and Smith (1993) defi ne a team as “a small number of people with complementary skills who are committed to a common purpose, perfor- mance goals, and approach for which they hold

Courtesy of Advocate Good Shepherd Hospital, Barrington, Illinois

Whatever the type, formal or informal, all teams must communicate to achieve their objectives.

Communication Process

Communication is an interactive process that occurs when a person (the sender) sends a verbal or nonverbal message to another person (the receiver) and receives feedback. The communica- tion process is infl uenced by emotions, needs, per- ceptions, values, education, culture, goals, literacy, cognitive ability, the communication mode, and noise ( Figure 5-1).

Communication in health care is used to coordi- nate patient care. Several studies of ICUs indicate that effective communication and coordination among clinical staff results in more efficient and better quality of care (Baggs, Ryan, Phelps, Richeson, & Johnson, 1992; Knaus, Draper, Wagner, & Zimmerman, 1986; Shortell et al., 1994;

Gittell et al., 2000; Young et al., 1997; Young et al., 1998). Additionally, research suggests that inef- fective coordination and communication among hospital staff contributes substantially to adverse events. For example, one study of the care of 1,047 patients in a large tertiary care hospital found that approximately 15% of the 480 adverse events iden- tifi ed, for example, failure to order indicated tests and misplaced test results, had causes related to the interaction of staff, such as the failure of a con- sultant team to communicate adequately with the requesting team (Andrews et al., 1997).

relationship patterns that emerge within workgroups ( Roethlisberger & Dickson, 1939). The workgroup has an impact on individual behaviors and attitudes because it controls so many of the stimuli to which the individual is exposed in performing organi- zational tasks (Hasenfeld, 1983).

Informal groups are not directly established or sanctioned by the organization but often form naturally by individuals in the organization to fi ll a personal or social interest or need. Shortell and Kaluzny (2006) identify a number of circumstances under which informal groups can have a negative impact on an organization. Groups may become overly exclusionary and lead to interpersonal con- fl ict. In other cases, informal groups can become so powerful that they undermine the formal authority structure of the organization.

Informal groups can assume a change agent role. Informal groups are often responsible for facilitating improvements in working conditions.

Such informal groups sometimes evolve into for- mal groups. Informal groups may also emerge to deal with a particular organizational problem or to work toward changes in organizational policies and procedures. In sum, informal groups play a unique role in organizations. These roles may be positive or negative.

A team may be advisory, such as a committee that meets to discuss concerns of the professional nurs- ing staff and then reports back to the chief nurse executive for decision making, or the team may be self-directed and make decisions on its own.

Influenced by:

Emotions Needs Perceptions Values Education Culture Goals Literacy Cognitive Ability Communication Mode Noise

Influenced by:

Emotions Needs Perceptions Values Education Culture Goals Literacy Cognitive Ability Communication Mode Noise

Verbal and Nonverbal

Message

Receiver Sender

Figure 5-1 Communication process. (Delmar/Cengage Learning).

For many types of health care organizations, staff communication and coordination is also relevant to their ability to comply with the requirements of accrediting bodies. In particular, both the Joint Commission (JC) (www.jointcommission.org), and the National Committee on Quality Assurance (web.ncqa.org), two leading accrediting bodies in the health care industry, have adopted standards that address coordination among professional groups, patient care units, and service components within health care organizations.

Note that communication is affected by follow- ing the rules of civility, e.g., do not demean others, show consideration, keep your voice low in public places, give praise, admit you are wrong, smile, etc.

(Forni, 2003).

Electronic Communication

Communication is shifting to an electronic mode, with computer technology playing an increasingly dominant role. Health care providers are using a variety of technologies, including telephones, voice mail, personal data assistants, BlackBerry, fax, e-mail, and video conferencing. These methods re- quire careful communication. For example, e-mail now allows almost instantaneous communication around the world, but it also accommodates indi- vidual preferences with respect to the timing of the response. This allows a person to send a message early in the day and allows the team members the opportunity to respond as their schedules permit.

Using e-mail may save a patient and caregiver from travel or loss of work. However, using e-mail requires that nurses acting in such a caregiver role have keen writing skills. The speed with which exchanges can now be made using technology has reduced the ac- ceptable response time. Therefore, the fi rst tip when communicating using technology is that it is impor- tant that both parties have an understanding about the circumstances under which different modes of communication will be used. Although one practitio- ner who is “connected” may be comfortable receiv- ing urgent patient information such as an elevated potassium level electronically, perhaps by e-mail, most practitioners expect a telephone call if the data being shared is potentially life-threatening.

Practitioners may be satisfied to receive a fax if the data are not urgent. Often, organizations have policies that guide under what circumstances a par- ticular mode of communication is used, so be sure to understand your institution’s policy for commu- nicating urgent information.

Another tip is to respond in a timely manner.

Timeliness is defi ned by what information is being shared and the route being used. A fax delivered to a practitioner’s office over the weekend will likely not generate a reply before Monday. E-mail, in general, provides greater immediacy, but the telephone remains the primary tool for communi- cating urgent information. Other tips for commu- nicating on e-mail include the following:

NO CAPITAL LETTERS—this looks like you

■

are shouting.

Be brief and reply sparingly, as appropriate.

■

Use clear subject lines.

■

Cool off before responding to an angry message.

■

Answer tomorrow.

Forward e-mail messages from others only

■

with their permission.

Forward jokes selectively, if ever.

■

Use good judgment; e-mail may not be private.

■

Keep in mind that accurate spelling, correct gram- mar, and organization of thought assume greater importance in the absence of verbal and nonverbal cues that are given in face-to-face encounters. Always proofread correspondences prior to sending them.

Imagine yourself as the recipient of the document.

Look for complete sentences, logical development of thought and reasoning, accuracy, and appropri- ate use of grammar, punctuation, and capitalization.

Electronic record keeping is increasingly being adopted by health care systems, particularly acute care settings. However, these systems are expensive to implement, so there is a lag between what’s available to improve record keeping and what is actually being used. The types and features of the systems adopted are almost as numerous as the institutions using them, so specifi c details will not be elaborated here. Orientation to each institution likely includes an introduction to the system(s) in use. In general, as with all patient records, issues of

law introduced new standards for protecting the privacy of individuals’ identifi able health informa- tion. There are 18 personal health identifi ers. This law also may apply to health information that is shared for research purposes (www.hhs.gov/ocr/

privacy/index.html.); see Table 5-1.

Stages Of Group Process

All teams go through predictable phases of group development as they evolve from an immature stage to a mature stage. It is critical to note that not all teams reach maturity, for a variety of reasons:

perhaps there is ineffective leadership, problematic members, unclear goals and communication, or lack of focus or energy. Some teams may become fully functional and mature quickly, bypassing a confi dentiality are of utmost importance, so nurses

must be mindful of their important role in main- taining privacy and accessing and granting access to the system appropriately.

Health Insurance Portability and

Accountability Act (HIPAA) of 1996

As nurses communicate today, they must increas- ingly be aware of patient privacy. The Department of Health and Human Services (HHS) has issued regulations known as the Privacy Rule that protect all individually identifi able health information held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. It applies to all health care plans, health care clearinghouses, and to any health care provider who transmits health information. The

Table 5-1

Elements That Are Considered Patient Identifiers Under HIPAA

■ Names

■ All geographic subdivisions smaller than a state, including street address, city, county, precinct, ZIP code

■ All elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, date of death; all ages over 89

■ Telephone numbers

■ Fax numbers

■ E-mail addresses

■ Social security numbers

■ Medical record numbers

■ Health plan benefi ciary numbers

■ Account numbers

■ Certifi cate/license numbers

■ Vehicle identifi ers and serial numbers

■ Device identifi ers and serial numbers

■ Web universal resource locators (URLs)

■ Internet Protocol (IP) address numbers

■ Biometric identifi ers, including fi ngerprints and voiceprints

■ Full-face photographic images and any comparable images

■ Any other unique identifying number, characteristic, or code unless otherwise permitted

Source: Compiled with information from U.S. Department of Health and Human Services. (2003). Protecting personal health information in research: Understanding the HIPAA privacy rule. NIH Publication Number 03–5388.

The second stage of the team process is the Storming stage. As the group relaxes and becomes more comfortable, interpersonal issues or opposing opinions may arise that may cause confl ict between members of the team and with the team leader.

This may cause feelings of uneasiness in the group.

It is important at this stage to understand that con- fl ict is a healthy and natural process of team devel- opment. When members of the team come from various disciplines and specialties, they are likely to approach an issue from several completely different standpoints. These differences need to be openly confronted and addressed so that effective resolu- tion of the issue may occur in a timely manner. Real teams don’t emerge unless individuals on them take risks involving confl ict, trust, interdependence, and hard work (Katzenbach & Smith, 2003).

The third stage is called Norming. After resis- tance is overcome in the Storming stage, a feeling of group cohesion develops. Team members master the ability to resolve confl ict. Although complete resolution and agreement may not be attained at all times, team members learn to respect differences stage or two along the way. It is typical for high-

functioning teams whose members are trusting of one another to be able to make decisions quickly and accurately; it may take longer for other teams, whose members need to get to know and trust one another, before the actual work can take place.

Tuckman and Jensen (1977) identifi ed fi ve stages that a group normally progresses through as it develops. These stages are known as group process and consist of: Forming, Storming, Norming, Per- forming, and Adjourning (Table 5-2).

The fi rst stage of the team process is the Form- ing stage. This stage occurs when the group is cre- ated and meets as a team for the first time. The team members come to the meeting with zest and a sense of curiosity, adventure, and even apprehen- sion as they orient themselves to each other and get to know each other through personal interaction and perhaps team-building activities. With the help of the team leader or facilitator, they will explore the purpose and goals of the team, what contribu- tion they can bring to the table, and set boundaries for the teamwork.

Critical Thinking 5-1

Y

ou are having a coffee break with another nurse who mentions a problem she is having with care delivery. The nurse is not sure how to solve it. You want to be helpful and supportive and yet avoid giving advice. Ask the nurse if she can describe the problem fully for you. Do not interrupt. Then, ask the nurse some questions about the problem, and seek clarifi cation until you are clear on the problem and the nurse has fully described it. Do not give advice. Use your communication skills, such as attending, clarifying, and responding, and ask the nurse such things as, tell me more about that, what did you think about it, and so forth, until you are both clear on the issue. At the end of this process, you can just fi nish by relaxing for the rest of your break or you can ask the nurse, “Do you want advice about your problem?”

Many times, this process will help the nurse solve the problem by himself or herself. If the nurse does want advice, you can give some suggestions if you are comfortable doing so. Do you think this process can strengthen people’s ability to fi nd answers to their problems? Do you think this process would be helpful to you in working with others on the unit?

Do you think this approach honors people’s integrity and ability to solve their own problems?

Source: Adapted from M. Parsons (personal communication, 2003).

as a whole. Kenneth Blanchard, one of the authors of The One Minute Manager, sums it up with his com- ment, “None of us is as smart as all of us.”

The fifth and final stage of team process de- velopment is the Adjourning stage. Termination and consolidation occur in this stage. When the team has achieved its goals and assigned tasks, the team closure process begins. The team reviews its activities and evaluates its progress and outcomes by answering the questions: Were the team goals sufficiently met? Was there anything that could have been done differently? The team leader sum- marizes the group’s accomplishments and the role played by each member in achieving its goals. It is important to provide closure or feedback regard- ing the team process to leave each team member with a sense of accomplishment.

of opinion and may work together through these obstacles to achieve team goals. Communication of ideas, opinions, and information occurs through effective cooperation among the team members.

Overcoming barriers to performance is how groups become teams (Katzenbach & Smith, 2003).

The fourth stage of the team development pro- cess is the Performing stage. In this stage, group cohesion, collaboration, and solidarity are evident.

Personal opinions are set aside to achieve group goals. Team members openly communicate, know each other’s roles and responsibilities, take risks, and trust or rely on each other to complete assigned tasks. The group reaches maturity at this stage. One of the biggest strengths of this stage is the emphasis on maintaining and improving interpersonal rela- tionships within the team as each member functions

Table 5-2

Tuckman and Jensen’s Stages of Team Process

Stages Description

Forming Relationship development: Team orientation, identifi cation of role expectations, beginning team interactions, explorations, and boundary setting occurs.

Storming Interpersonal interaction and reaction: Dealing with tension and confl ict or confrontation may occur.

Norming Effective cooperation and collaboration: Personal opinions are expressed and resolution of confl ict with formation of solidifi ed goals and increased group cohesiveness occurs.

Performing Group maturity and stable relationships: Team roles become more functional and fl exible, structural issues are resolved leading to supportive task performance through group-directed collaboration and resources sharing.

Adjourning Termination and consolidation: Team goals and activities are met leading to closure, evaluation, and outcomes review. This may also lead to reforming when the need for improvement or further goal development is identifi ed.

Source: Compiled with information from Tuckman, B. W., & Jensen, M. A. C., (1977) Stages of Small Group Development Revis- ited. Group and Organizational Studies, 2(4), 419–427; Hall, P., & Weaver, L. (2001). Interdisciplinary Education and Teamwork: A Long and Winding Road. Medical Education, 35, 867-875; Polifko-Harris, K. (2003). Effective Team Building. In P. L. Kelly, Nursing Leadership & Management. (2nd ed.). Clifton Park, NY: Delmar Cengage Learning.