Communication A Pillar of Collaboration
Skilled communication is an essential element of collaboration. (AACN), 2005)
maria
Maria, a 26-year-old registered nurse, has been working on the orthopedic unit of a community hospital for the past year. Her manager asks her to participate on a multidisciplinary team tasked with developing a “bundle” of interventions to reduce infections in patients undergoing total hip replacement; the infection rate has risen in the past few months. The team includes a surgeon, anesthesiologist, pharmacist, clinical nurse specialist for the orthopedics unit, and an OR specialty nurse, among others.
Maria is excited about being part of the team, but soon that excitement turns to disappointment. She feels other members of the team, all of whom are older than she, aren’t listening to her suggestions and soon she clams up. She also witnesses verbal sparring over turf issues between the OR specialty nurse and the orthopedic unit clinical nurse specialist and hears sarcastic comments by some team members. Although the bundle is developed, it takes much longer than expected and leaves Maria with little desire to “collaborate” again. The bundle itself is not as comprehensive as it should be and does little to reduce infection rates.
Three months later, the committee is reconvened and includes Maria, but also has some different members. This time Maria’s experience is far more positive. She feels heard and respected by all members of the committee, who are of different generations. The revised bundle ends up reducing infection rates by 30%.
The collaboration spills over outside the committee as well. Maria feels the surgeon respects her expertise, and she is sure to present patient information and make requests succinctly. Maria ends up consulting with the pharmacist about a drug she is unfamiliar with, which results in a medication error being averted. She witnesses firsthand the value of effective collaboration.
It is estimated that a typical patient may encounter 50 healthcare providers over a four-day hospital stay, including physicians, nurses, and numerous support staff (O’Daniel & Rosenstein, 2008). Each member of the team has specific patient care goals in the larger context of a single goal—to provide optimal care; each role is essential, each is complementary. The only way to combine these distinct and separate orbits into an integrated system is through “frequent, respectful, and skilled communication” (AACN, 2005, p. 16). Thus, without communication, collaboration is not possible.
In an analysis covering 2004 to 2012, the Joint Commission (2013) found that communication issues were the top reason for death related to a delay in treatment, and from 2010 to 2012, they were the third highest most frequently identified root cause of sentinel events. Many of these events would have been preventable if appropriate communication had occurred. Communication is a two-way process that inherently demands questions and clarifications (ANA & NCSBN, 2006). Communication must happen in health care, regularly and often, in whatever form might be most effective in a given situation (e.g., in-person interactions for complex discussions versus email or text for simple and clear information) (Safran, Miller, & Beckman, 2006).
Not communicating at all is a core issue in communication breakdown (Maxfield, Grenny, McMillan, Patterson, & Switzler, 2005). Several years after the wake-up call regarding the state of healthcare delivery from the Institute of Medicine (IOM) in To Err Is Human (IOM, 2000), another breakthrough study report was published, this time by VitalSmarts, an organizational performance company, in conjunction with the American Association of Critical-Care Nurses (AACN) and the Association of periOperative Registered Nurses (AORN) (Maxfield et al., 2005). Entitled Silence Kills, the authors identified seven areas in which healthcare providers frequently failed to communicate, even when observing blatant oversights and errors (see Table 1). Sadly, this research also revealed that fewer than 1 in 10 healthcare workers discussed these concerns.
Why does the highly intelligent healthcare workforce often have trouble communicating? One major obstacle: fear of discomfort, of retribution, of job security.
Table 1. Situations Most At Risk for Communication Breakdown | ||||||||||||||||||
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But why, when communication seems a fairly simple concept, does the highly intelligent healthcare workforce have such trouble executing it?
One major obstacle is fear: fear of discomfort, of retribution, and of job security. A follow-up study to Silence Kills, entitled The Silent Treatment, found that over half of the approximately 2,500 nurses surveyed (169 managers, the remainder direct care RNs) either did not feel safe to speak up or felt that they weren’t listened to (Maxfield et al., 2011).
Communication, Collaboration, & YOU
Remember a time when you witnessed disrespect, lack of support, or even incompetence and didn’t speak up. How did it make you feel? Now compare it to how you felt when you did choose to speak up.
Interprofessional Communication Challenges
Fear creates anxiety and mistrust, which leads to failures in communication and a lack of collaboration and teamwork.
Collaboration cannot come to fruition unless individuals at all levels of the organization consider themselves equals in the collaborative process, with an equitable distribution of power. Nurse-physician collaboration is fraught with roadblocks, many of which can be traced back to the archaic model of a nurse as a physician’s handmaiden (Ellingson, 2002). Although the relationship has positively evolved over the last several decades, some experts argue that progress has reached somewhat of a standstill. This power struggle is attributed to several factors:
Increased number of female physicians
Increased use of nurse practitioners
Increased nursing autonomy
Decreased perception of physician esteem due to accessibility of health information online (Nair, Fitzpatrick, McNulty, Click, & Glembocki, 2012)
Additionally, nurses and physicians tend to hold different views in regard to patient needs and goals (O’Daniel & Rosenstein, 2008) and may differ even more fundamentally in the perception of how effective collaboration is defined (Jensen, Ammentorp, Erlandsen, & Ording, 2011; Marshall & Robson, 2005; Nair et al., 2012; Vazirani, Hays, Shapiro, & Cowon, 2005). The development of the nurse-physician relationship deserves continued attention and discussion, especially since the perception of satisfactory collaboration between nurses and physicians is linked with a number of improved outcomes including decreased lengths of stay, decreased mortality, and improved patient satisfaction (Kenaszchuk, Wilkins, Reeves, Zwarenstein, & Russell, 2010; Maxfield et al., 2005; Nair et al., 2012; Siu, Laschinger, & Finegan, 2008). Successful collaboration is also linked with an increase in the nurses’ perceptions of quality of care, which has a significant impact on job satisfaction, morale, and turnover (Nair et al., 2012; Siu et al., 2008). Cultivating improved nurse-physician communication and collaboration, in spite of its challenges, can have a major impact on the quality of health care delivered.
Similarly, one should consider the large number of interactions that take place between nurses and unlicensed personnel/ancillary staff. These communications are of equal importance and require respect, specificity, and clarity. In a joint statement on delegation, the American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN) (2006) include right communication and direction among the 5 Rights of Delegation. Communication should be respectful, timely, and include a rationale that gives a delegated task meaning (Anthony & Vidal, 2010).
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