- teamwork
a way of working that involves ‘listening and constructively responding to points of view expressed by others, giving others the benefit of the doubt, providing support to those who need it, and recognizing the interests and achievements of others’ (Katzenbach & Smith, 1993, p. 15).
The practice examples in this chapter illustrate intra- and interprofessional communication issues, one involving spoken and the other written communication. One central issue is continuity of care, as this relies on adequate handover of the care of patients (orally and accompanied by patient records) among health professionals when they change shifts or when patients are referred from one team or location to another.
Introduction
Health care is complex, frequently highly specialised and delivered by a growing number of health professional groups. Each health profession defines its own roles, and within each profession there are different subdisciplines, each with their own demarcations of responsibilities. For example, medical doctors may be surgeons, cardiologists, pathologists, and so forth. Nurses may be advanced practice nurses, nurse practitioners, remote area nurses, enrolled nurses, and the like. For their part, allied health professions have their own role and status demarcations.
Each professional group and subgroup has its own values and priorities, jargon and hierarchy. This creates the potential for miscommunication and adverse patient or client events. (Note that the health professions may refer to the consumer of care in different ways: patient, client, or service user.) Most patients will interact with several types of health professional during an acute or chronic illness. Such professionals may be collaborating quite intensely in a co-located team (in the operating room, or on a ward), or they may be in looser collaborations and have quite infrequent interactions (in community settings).
Effective teamwork means providing quality health care in whatever environment, whatever its complexity (Romanow, 2002). Effective teamwork also presupposes that clinicians cope with technological advances in diagnosis and patient management (Institute of Medicine, 2001). Both these kinds of team effectiveness are crucially dependent on effective communication: are team members able to talk about problems that arise, are they able to exchange important knowledge, and are they able to help each other come to terms with new technologies and information?
It has been clear for some time that effective communication is a marker of good teamwork and it leads to fewer errors (JCAHO, 2005). By the same token, suboptimal communication is a marker of ineffective teamwork, and is a prime cause of patient safety problems and poor patient outcomes. Ineffective teamwork was found to be at the heart of problems affecting acute hospital services in New South Wales. The Garling report, reporting on a state-wide investigation into New South Wales emergency health services in 2008, recommended that ‘clinical education and training should be undertaken in a multidisciplinary environment which emphasises multidisciplinary team based patient-centred care’ to help prevent further problems (Garling, 2008, p. 11).
- multidisciplinary team
a team comprised of professionals from different backgrounds
Note that there are several words that are frequently used synonymously: interprofessional; multi- and interdisciplinary; and multiprofessional. However, we feel that ‘interprofessional’ teamwork best describes what is at issue here: how to achieve ‘two or more professions working together as a team with a common purpose, commitment and mutual respect’ (Freeth et al., 2005). We define multiprofessional teamwork as carried out by professionals working in parallel with little interaction and infrequent communication.
For us, optimal team functioning requires professionals to be able to do two things. First, they need to be able to negotiate a common purpose and shared goals. Second, they need to have regular meetings where they reflect on their performance (Dawson, Yan & West, 2007). Health professionals who identify themselves as working in teams but who do not meet frequently to set goals and reflect on performance report less job satisfaction and more burnout, and have a greater likelihood of being involved in adverse events (Dawson, Yan & West, 2007). Important skills to learn for teamwork include communication in general but also more specific competencies:
- interprofessional communication;
- patient-/client-/family-/community-centred care;
- role clarification;
- team functioning;
- collaborative leadership;
- interprofessional conflict resolution (CIHC, 2010).
Dysfunctional teamwork leading to poor intra- and interprofessional communication has five common features. The first is a lack of trust. Trust is defined as the willingness to rely on others’ skills and judgment. A lack of trust may be due to not knowing the scope of practice and role and skills of other health professionals: what they are responsible for and capable of doing. In the healthcare environment you need to be able to ask each other what your responsibilities are and to discuss the limits of your practice.
The second, fear of conflict, means that one professional may avoid questioning another’s behaviour. Avoiding questioning colleagues for fear of conflict is a prime cause of adverse events. Fear of conflict may also result in a lack of commitment to establishing common goals. A team member may not agree with the stated goals but is afraid to let this be known. Remember that conflict can be productive if there are agreed ground rules for all communication, and all communication involves mutual respect so that each team member feels able to speak and is listened to.
It may be though that there is undue pressure to share each other’s personal and professional values within the team. Values here mean ‘standards by which our actions are selected’ (Mason et al., 2010, p. 71). Such pressure to agree on values may explain why at times team members fear conflict will arise when questioning team values. Such questioning is particularly problematic when team values are out of alignment with patients’ values. This may create difficult situations for clinicians who feel torn between conforming with their team and providing patient-centred care.
Being able to question and renegotiate values to ensure they remain patient-centred means that practice is ‘values-based’. Values-based practice is ‘a blending of the values of both the service user and the health and social care professional, thus creating a true, as opposed to a tokenistic partnership’ (Thomas, Burt & Parkes, 2010, p. 15).
- values-based practice
care that adheres to moral values such as empathy and person-centredness. Values-based practice can be distinguished from task-based practice. Where values-based practice unfolds in response to patients’ needs, task-based practice is driven by pre-determined (and often clinician-defined) structures and activities.
Five characteristics of dysfunctional teams are as follows:
An example of intra-professional conflict is between hospital doctors in different specialties. This conflict was expressed through clinicians’ contributions to the patient’s written medical record (chart). In this case (taken from Hewett, Watson & Gallois, 2013), a patient’s chart across a single afternoon revealed escalating conflict between an emergency medicine specialist and a gastroenterology registrar (a junior doctor receiving training as a specialist) in a large hospital. The conflict concerned the treatment for a patient with an upper gastro-intestinal bleed. This serious and potentially life-threatening condition requires immediate treatment. Best practice guidelines indicate that an upper endoscopy (examination via inserted camera of the upper gastro-intestinal tract) should be performed to diagnose (and in some cases treat) the cause of the bleed as soon as possible, and certainly within 24 hours of admission.
A department of emergency medicine (DEM) resident medical officer (RMO, a recent medical graduate receiving general hospital training) initially reviewed the patient on presentation to the DEM. Summarising his colleagues’ discussion and decision, this RMO wrote in the chart that the patient should go for admission and endoscopy (‘scope’). The first entry in the medical record appears at 2:30 p.m. (1430 hours); pseudonyms are used for all doctors.
[Extract 1:] 1430h Discussed w DEM reg (Dr [Allan]): to be admitted medically. Spoke with Med Reg 4B Dr [Baker] – she will kindly r/v but suggests discussing with endoscopy reg re ?urgent scope. D/W Dr [Young, registrar in gastroenterology] – will try and arrange scope for today. Pt fasting since 7am. [signature]
More than two hours later, at 4:50 p.m., the emergency department (ED) consultant (Dr Wilson, the emergency medicine specialist), who had not previously been involved in the patient’s care, wrote the following:
[Extract 2:] 21/4/05 DR [Wilson] ED 1650: Phone call from Dr [Young]: wanting bed in DEM post-procedure advised none available no endoscopy will be performed as no bed available post-procedure (as per Gastro consultant decision).
An hour and a half later (at 6:00 p.m.), the gastroenterology registrar (Dr Young) recorded a one-and-a-half page entry of narrative text, which began:
[Extract 3:] 21/4/05 Dr Young, GE reg. I was paged about this man at 1330h. I saw him in DEM immediately after I completed the urgent procedure I was doing (about 1430h). I consented him and booked a bed + explained the priority for a bed to the ED nurses at this time. I also spoke to the involved Med Reg. I arranged to do the case [procedure] in the endoscopy unit at the end of our pm list with an anaesthetist.
Later in the entry, the gastroenterology registrar continued:
[Extract 4:] No bed was available for the patient at 1630. I discussed the need for him to return to DEM after the case with Dr [Young]. Dr [Young] declined to accept the patient back to DEM. I called the bed manager … and was again told there was no possibility of a bed. I again spoke with Dr [Young] who advised me that the case could not be done.
The gastroenterology registrar then described referring the problem to the hospital’s Chief Executive Officer (CEO), a significant escalation of the conflict. The CEO was able to broker a solution. The final statement from the gastroenterology registrar (before the endoscopy report) concluded:
[Extract 5:] The case therefore was done in [the operating theatre], after hours, when it could have occurred in the endoscopy unit during hours.
Analysis and reflection
The record starts in a fairly straightforward way (extract 1), and illustrates the cryptic style in which doctors are trained to write in charts. The medical and nursing records are often kept separately, particularly if in paper format. Note that nurses are trained to use a more narrative style in the patient record, which places more emphasis on patients’ behaviour and progress. This style difference can lead to inter-group conflict, mainly exemplified by nurses and doctors claiming not to understand each other’s chart entries (or in the case of doctors, not always reading them carefully). In extract 1, there is an expression of thanks to the registrar in general medicine (Med Reg 4B: ‘she will kindly review’), and trust that she can arrange things with the gastroenterology department. There was also a note about the urgency of the situation and the need for an endoscopy that day.
Things did not proceed smoothly, however. A conflict about the patient appeared in the chart soon after presentation at the ED, as extract 2 shows. Two hours later, the emergency medicine specialist, Dr Wilson, had intervened and was laying responsibility for any adverse consequences at the door of Dr Young, the gastroenterology registrar, as well as indicating a lack of trust of Dr Young and Dr Young’s senior consultant. In contrast to the cryptic style used in extract 1 which had concentrated on the patient’s condition and intended treatment, extract 2 presents a longish narrative description of the conversation about bed availability. This departure from standard cryptic medical notation often appears when there is intra-professional conflict among doctors.
In the final entries (extracts 3, 4 and 5), which are all part of a longer narrative, no discussion of the patient or his condition or treatment appears. Rather, the discussions between doctors in gastroenterology and emergency are detailed by Dr Young, the gastroenterology registrar. Dr Young appears to be concerned to set down the gastroenterology department’s side, which is that an endoscopy cannot be performed unless the patient has a bed to go back to. Dr Young blames the other departments, particularly emergency, which is specifically named four times in the extracts. Dr Young describes the consequences of the conflict (that the procedure was performed late and out of hours in surgery, when it should not have been). Again, however, no mention is made in this long narrative of the patient, his condition or progress, or his treatment, other than that the endoscopy was eventually performed. Dr Young seems to be mainly concerned to detail the conflict. The patient has been forgotten, at least temporarily.
These extracts show escalating distrust and conflict between, in this case, the emergency and gastroenterology doctors. The context and history are relevant: a significant history of interdepartmental conflict relating to contested responsibilities for patient care. As the RMO in the ED was probably not aware of this context, the initial entry was polite and accommodating. A clear and deliberate statement was made about the patient’s fasting status, critical information for the gastroenterology team in planning the timing of the procedure.
By contrast, the entry by the ED consultant (Dr Wilson) was unheralded. It signalled distrust of the motivations of the gastroenterology doctors (to claim an ED bed), reflecting inter-group conflict and escalating hostility between the groups. The entry prompted a detailed defence by the gastroenterology registrar. He concluded with a statement about the perceived inefficiency and waste stemming from the ED’s refusal to continue the care of the patient after the endoscopy.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
