CHAPTER 12

Communicating Effectively on Healthcare Teams

As healthcare systems change, one area that is becoming more and more critical is teamwork. Nowadays, even a solo clinician in practice typically depends on a whole team of individuals, including nurses and support assistants, to get the work done. Emergency departments and surgical practices need more staff than ever before, including roles in trauma rooms and operating theaters. Inpatient settings have also seen a vast increase in necessary staff: in the 1970s, there were approximately 2.5 employees for every hospitalized patient—in the 1990s that number had increased to 15.¹

Nearly every healthcare worker has had mixed experiences with working as part of a team. Similar to having multiple people in an exam room (see Chapter 3), an increase in the number of team members often results in exponentially more complex interactions and communication. Team training modules such as TeamSTEPPS, a teamwork system developed by The Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD), invoke the importance of communication and have formats for information transfer, such as ISBAR.² However, there still remains a need to identify specific processes to enhance interactions and facilitate effective communication. This chapter identifies how communication can be used in teams to increase efficiency and improve quality of care.

Characteristics of Highly Functioning Teams

From sports to academics, we have all been on countless teams throughout our lives. When we reflect on the most remarkable teams we have been a part of, we can easily see how those teams stood out from the rest.

Take a moment to think about what made your most remarkable teams so special. Maybe they were just great fun to be on. Maybe you shared a competitive drive with other teammates or a desire to make beautiful music together.

When you think about what made your favorite teams special, you will most likely name one of the four characteristics of highly functioning teams:

1.   Cohesion: the extent to which people feel valued on the team (With good cohesion, team members find their experiences meaningful.)

2.   Communication: how the team processes information and how it handles diversity, feedback, and conflict

3.   Role Clarity: whether the roles and responsibilities of team members are understood by all on the team

4.   Goals and Means Clarity: the team’s overall goal is clear and shared by all, and the means of getting there is also clear

There are many similar lists that describe what makes a great team. This framework has been validated in healthcare settings with a measure that can be relatively easily administered.³ We will focus on cohesion and communication, as these unsurprisingly encompass most of the communication tools that lead to highly functioning teams.

COHESION

The first and most important step toward creating a highly functioning team is developing trust and cohesion among team members. Without trust, the other three characteristics of highly functioning teams cannot occur.⁴

Most of us have been a part of healthcare teams that have failed to meet their goals. Why do teams fail? Often, unanticipated dynamics or circumstances within the team can get in the way of meeting a shared objective. The operating room (OR) is characterized by teamwork, expertise, high stress, and at times unmet expectations. The following is an example of a common experience in the OR:

It was the end of a busy day. Most surgeries were completed, with the exception of a trauma case, which was taking much longer than anticipated. The surgeon was operating on the patient’s fractured tibia. A second patient came in needing immediate surgery. Typically, the patient and the medical team would have to wait for the routine cleaning to take place before a room would be available. Because a previous case had finished early, a second room was already prepped for the new patient. The surgeon, pleased at the possibility of finishing his work for the day, asked others to finish his current case so that he could start the next one. He left a junior resident in charge of the patient with the fractured tibia and called in a physician assistant to close the case. The surgeon and his chief resident left to start the final case. The surgical technician stayed overtime and a new circulating nurse came in to help.

During changes like this, medical staff performs a “count” to make sure that all needles and sponges are accounted for before closing the incisions. The count concluded that a large sponge was missing. But the incisions in the leg were far too small to harbor a large sponge. The resident in the room said, “The count must be wrong. There’s no way a sponge is in there. Please recount.” The surgical technician agreed. The incoming circulating nurse reluctantly acquiesced, knowing that the whole operation would be stalled until the recount was completed. The physician assistant commented sotto voce that the sponge was “probably in the garbage.” When the second count confirmed a missing sponge, emotions started to run high. The resident wanted to observe the other case that was just starting, and the physician assistant who was called in to help close had been leaving for the day. The surgical technician was offended at the comment about a sponge being in the garbage because it was her job to keep track of the sponges. The circulating nurse felt pressured by the other medical staff to “get things moving.” The incident was extending the surgical time by more than 30 minutes.

Tempers flared, and the charge nurse was summoned to gain control of the situation. She entered the room and facilitated introductions from all team members. She carefully prompted each person to be concise and listened intently to the different perspectives, acknowledging each person’s emotions. Having created quick rapport with everyone, she asked for ideas from the group. As the physician assistant had suggested, the sponge was found in the garbage, thrown there, as it turned out, by the surgeon prior to his departure from the room.

This story demonstrates how a team that was thrown together as part of a good idea had no cohesion. They didn’t share common goals. When the charge nurse came onto the scene, she developed quick rapport with all team members and added cohesion to the team.

Too often, healthcare teams do not adequately get to know each other, not only in terms of their roles on a team but also personally. Turnover on teams, inability (or unwillingness) of team members to attend regular meetings or huddles, and diverse perspectives also can contribute to the lack of cohesion.

There are some reasonably simple but highly effective tools that can develop cohesion in a team. These tools mirror the skills of the fundamental skill sets (see Chapters 3–5):

•   Greeting: Every meeting should begin with check-ins. These should be brief, one-sentence statements of how someone is doing and whether someone has to leave early. That way, there are no team meetings that begin with factual information, only to be interrupted by a key team member who has to duck out prematurely. Check-ins allow team members to remove themselves from the trance of usual work to be fully present and honest about their needs. Check-ins can further be enhanced by some small icebreaker questions, such as, “What’s keeping you going today?” It may sound trite, but as human beings, particularly in healthcare, we all desire connection.

When we introduce check-ins, we should set ground rules to make sure check-ins don’t take over the meeting. Cohesion efforts are important, but they shouldn’t drag out to the point where they replace work.

•   Introductions: Getting to know new team members, especially in high turnover situations, is key. If we haven’t worked to integrate new people into a team, we cannot assume that they will just get up to speed automatically. It is admittedly a “speed bump” when someone new enters a position, but the speed bump can transform into a series of deep potholes and unintended poor communication in the absence of simple introductions.

•   Team Meeting Agenda-Setting: Ideally, agendas for meetings are set ahead of time with input from team members. With adequate attention to process, meetings can then predictably start and end on time. If there is no agenda, participants should be asked concisely for a list of items they would like to cover, and then an agenda can be set. Otherwise, the meeting will achieve the ignominious, all-too-common categorization of “a waste of everyone’s time.”

•   Relationship-Centered Skills: When emotions arise in a meeting, as they often do, using reflective listening and PEARLS (see Chapter 4) is necessary to further the cohesiveness of the team. Unless the group is particularly high functioning, hurt feelings on a team typically do not heal themselves. Instead, hurt feelings arise at inopportune moments, either underground in a way that undermines the work of the team, or openly and disruptively.

•   Next Steps: Defining clear next steps at the end of a meeting, ideally using skills delineated in Chapter 5, not only will make the work of a team move forward but also will set accountability for work to be done. (This practice also supports another team characteristic, goals and means clarity.)

Even though the operating room story doesn’t technically fall into the category of a “team meeting,” team members had not introduced themselves, and were further hampered nonverbally by wearing surgical caps and masks. A quick set of greetings, a check-in, and agenda-setting about goals for the task at hand could have saved precious time. With relationship-centered skills, perhaps the quickly assembled team could have achieved closure without waiting for the charge nurse. Assiduously introducing these fundamental communication principles to healthcare team meetings can strongly enhance cohesion and trust development.

Cohesion creates an environment of inclusion that encourages creativity. One method to facilitate this is appreciative inquiry (AI). Appreciative inquiry is a way of asking questions of the team that encourages emphasis on the strengths and positive experiences rather than looking for problems and obstacles to success. The idea of AI is to note when something is working well and then ask, “What factors helped make this a good experience?” A follow-up question could be, “How can we use this strength in other circumstances to create another good experience the next time?” By asking appreciative questions, we recognize team member contributions, thereby reinforcing those behaviors and improving morale.

The Physician Assistant graduate program at Daemen College in Amherst, New York, where I (Jim Bell) am faculty, is an example of the benefit of AI and diversity. The full-time faculty is a mix of academics and practicing clinicians. The program director actively sought diversity when adding to the faculty over recent years, hoping to build from varied strengths. The team has equal gender representation and includes an MD pathologist who teaches anatomy; a psychologist who teaches writing, research, and statistics; an English professor who teaches research methods, writing, and interviewing skills; and practicing physician assistants in pediatric psychiatry, orthopedic surgery, emergency medicine, urology, cardiology, family practice, and asthma/immunology. The mix of perspectives has resulted in some very creative ideas on how to teach medicine to students, as well as significant respect for the expertise of all faculty members. Faculty members even ask each other occasionally for personal consultations for themselves and their families. The expertise of each member is more important than title or seniority and allows for more inclusive discussions and increased cohesion. There is a high level of trust among team members.

Relationships in teams take time to build—one check-in will help in the moment but will not suffice for the long term. In the current era of fragmentation of care and the necessity of handoffs, relationship development has never been more important. Some tools to use to foster relationships in the team are regular structured feedback (see Chapter 10), team huddles, and supported inclusive interactions outside the workplace. Suggested activities include retreats, local job fairs, community outreach activities, or social activities such as sporting events. Even just having lunch together as a team can enhance relationships among team members.

COMMUNICATION

As cohesion develops, using the fundamental communication skills listed in the previous section, the team can begin to move into advanced applications of these fundamental skills, two examples of which are feedback and huddles. Another important example is when conflict develops between team members (see Chapter 13).

Feedback on Teams

Many of us dread giving and receiving feedback. Yet productive feedback is critical for relationship building, personal improvement, and professional development. Why is feedback so uncomfortable for so many of us? It’s the way feedback is usually delivered that makes us cringe. If our supervisors give feedback intermittently, without warning, and focus solely on problem areas, it’s no wonder we develop negative feelings about the process. Feedback doesn’t have to be something we dread. Feedback is productive and often welcomed when it is part of a regular, structured process that involves an honest dialogue about both strengths and opportunities for improvement. Regular, structured feedback can encourage deeper connection, provide opportunities to voice emotions that may be under the surface, and increase the productivity and satisfaction of team members.

Two research scientists were working in a lab studying the properties of inhalant medications. Anna worked early in the morning, and Brian worked in the evening. They were friends and set periodic meetings to check in about the project. Brian had trained Anna on the equipment and procedures. As the project “lead,” Anna was responsible for productivity. At one point in the project, Anna encountered a problem. Each morning she came to begin work, she discovered that the lab was set up differently from how she had left it. For three days, she spent 30 minutes reorganizing the lab before she could begin work. Finally, she asked for 15 minutes to meet with Brian to give feedback about lab procedures.

At their meeting, the two scientists began with a check-in. Anna told Brian that the project was on schedule and under budget. She also mentioned that she had discovered an alteration in the setup for each of the past three nights. Brian smiled and proudly indicated that he had developed a newer and more efficient way to do the tests (which was why they were under budget) and was pleased. Anna said, “It’s great that this project is going well and that you are being creative. I really appreciate that.” Anna paused to allow the initial feedback to settle in. Then she added, “Would you be open to something I’ve noticed?” Brian said, “Of course.” Anna continued, “I find that due to your changes, I’m having to catch up each day, which puts me behind in the morning. Can you think of a way that we could keep being creative and efficient where I don’t have to spend time catching up?” Brian expressed surprise that his ideas had caused mild chaos in the morning. In the future, he promised to call her if he changed something. They also agreed to have conversations on Fridays over beer to summarize changes during the week.

There was real potential for conflict in this situation. Brian was unintentionally making things harder for Anna. But they checked in with each other; agreed on an agenda so that no one felt ambushed; engaged in dialogic feedback, expresseing understanding about what the other was experiencing; and sought clarity of intent. They also established a regular opportunity to exchange feedback in the future. Had they handled the potential conflict differently, they could have ended up feeling resentful while making assumptions about the other person’s intent (see Chapter 13). Instead, because they communicated so effectively, the potential conflict actually enriched their relationship.

Obviously, feedback among members of larger teams can become quite complicated. As a result, fundamental feedback skills for large teams are even more critical. Often, corrective feedback for an individual team member should be done in private. But clever workarounds are possible.

On an inpatient internal medicine team of a nurse practitioner and physician assistant, the supervising physician notes that Ms. Evans, the physician assistant, thinks through the biomedical details of the case carefully, sometimes at the exclusion of understanding patients’ biopsychosocial details. Mr. Phillips, the nurse practitioner, comes up with excellent discharge plans because of his deep understanding of patients’ home situations, but the biomedical summaries are less crisp. On rounds, the physician says, “Ms. Evans, I love the way you so thoroughly go through each patient’s differential diagnoses. Mr. Phillips, your social histories really make discharge planning a breeze. Thanks to you both.”

On rounds the next day, guess how Ms. Evans changed her social histories, and how Mr. Phillips went through his differential diagnoses?

Team Huddles

Team huddles help to build spaces for both communication and relationship enhancement. As in football, huddles in healthcare settings are brief team meetings to discuss the current factors affecting the work of the day. These are not meant to be sit-down meetings with agendas and do not take the place of regularly scheduled meetings. Huddles vary in their goals and content but typically begin with initial check-ins, followed by updates of anything that is immediately relevant. Teams leading training and educational sessions will routinely huddle in the beginning of the day and at periodic breaks for as short as 30 seconds.⁵ During one of these huddles, a team member indicated that a medical emergency had arisen with his son. Team members expressed their concern, assured him that he should leave to take care of his family, and then swiftly divided up his portion of the day’s activities. A potentially disruptive event was efficiently addressed in a very short time because huddles were a regular part of the team and because team members had established relationships.

Putting It Together

At a large tertiary referral center, inpatient cardiology services were provided by teams of residents led by attending cardiologists. There were enough residents to build three teams (Cardiology 1, 2, and 3). The outcomes of this system were very good in terms of number of adverse events, length of stay, overhead cost, and patient experience.

Eventually the number of patients needing inpatient cardiology services grew to be too large for three teams. Rather than create a new system for providing cardiology care, the institution decided to create Cardiology 4, a team of nurse practitioners and physician assistants instead of resident doctors. Six months after the creation of Cardiology 4, it came as a surprise to everyone that every metric used to determine effectiveness of the team (overhead cost, duration of stay, adverse events, patient experience) was significantly better in the patients treated by Cardiology 4 than for all of the other teams.

Now that we know some of the characteristics of highly functioning teams, it should be no surprise why Cardiology 4 succeeded. There was a high amount of cohesion due to the permanent nature of the team members in Cardiology 4. This facilitated much richer relationships around care both within the team and with the other services. The team met in huddles frequently. This fact, combined with the team members’ familiarity with each other, made more lengthy meetings unnecessary. Each team member’s opinion was sought and the diversity of experience and profession was embraced. The hierarchy was much flatter on Cardiology 4, which promoted dialogue and an openness for creativity that did not exist in the much more traditional hierarchy of the resident teams. Individual clinicians consulted with each other nearly constantly. Feedback was common and frequent among members of the team. Although feedback was present on the resident teams as well, the frequency of the feedback in Cardiology 4 was higher and the content generally much more supportive.

Conclusion

Enhanced team communication and collaboration leads to improved patient experiences, better clinical outcomes, and reduced patient complaints. High-performing teams also experience heightened morale among team members and increased staff retention. Cohesion, communication, role clarity, and goals and means clarity are necessary to create high-performing teams. Teams can be created and enhanced using basic communication skills such as expressing empathy, managing conflict, giving effective feedback, supporting team member inclusion, and enumerating clear next steps. As team members learn to attend to the needs, strengths, and diverse backgrounds of colleagues, they enhance collaborative team performance.