Good teamwork is as essential to a high-functioning nursing unit as the nurses themselves. Even the best nurses can’t operate in a silo–patient care takes a comprehensive and cohesive approach where nurses know what to do, know what everyone else does, and each nurse supports the rest of the team.
Despite being a fundamental nursing practice, teamwork can be challenging. Some teams don’t work well and don’t know what’s wrong, or they know what’s wrong and don’t implement solutions that work.
So what’s the key to good teamwork?
It’s all about communication.
“This applies to all professions–communication is key,” says Dr. Margarita David, DNP, MSN, BSN, BA, RN, PCCN, CSN, founder and CEO of Dr. Registered Nurse Success Academy, LLC. But fine-tuning communication skills sometimes gets pushed aside for the immediacy of nursing duties. “Many nurses get overwhelmed with doing what the job requires and what needs to be completed. There’s not enough time.” The dangers of an ineffective team are many; the worst outcome is when it causes patient or nurse harm. For example, patients who leave the hospital without a clear plan or a plan they need help understanding are more likely to be readmitted within 30 days. “That also affects a hospital’s numbers,” she says. “It’s a domino effect.”
Developing Skills and Practice for Effective Work
Dr. Margarita David is the founder and CEO of Dr. Registered Nurse Success Academey, LLC
Teamwork can be guided, but it can only succeed with flexibility. What works for one team may not hold for how another team operates. So constantly reassessing how a team works–its strengths and weaknesses–is necessary. “In nursing, everything changes every single day,” says David.
Building teamwork skills often starts when nurses are still in school, says Dr. Shelley Johnson, EdD, MSN, MBA, RN, NE-BC, CNE, dean and professor at Florida Agricultural and Mechanical University’s School of Nursing. “In nursing education, there’s a lot of content delivery, and we ask students to work on communicating with each other for support and to talk through difficult concepts,” she says, noting that a tried-and-true method that nurses can use throughout an entire career span is the SBAR method. Presenting problems and solutions with the SBAR method helps nurses identify issues and background, assess, and then recommend how to solve things; it’s a method that can be used in many situations. “They can use the SBAR format if they are going to a faculty member with an issue, or they can use it in a presentation to advocate for themselves, others, or as a leader.”
Dr. Shelley Johnson is the dean and professor at Florida Agricultural and Mechanical University’s School of Nursing
According to David, nurses should seek opportunities to intentionally put themselves in positions to grow confident speaking up because that’s what it takes to be an effective team member and leader. “Get involved in a research council or on practice committees,” she says. “Get involved, and then put yourself out there.” Because so much of nursing is focused on direct patient care, nurses have fewer chances to speak in front of others or to gain the confidence that comes from that experience. Nurses can also actively practice at conferences and meetings where they learn to communicate what they want.
Johnson says that when nurses grasp the skills that will strengthen their team, standardizing the language and process makes a difference. “You want it to mean the same thing when there’s an emergency,” says Johnson, “so no one is confused.”
And if tension does develop, team members need to recognize the problem, reassess the approach, and address it. Take a step back and wait for things to deescalate, says Johnson, and then come from a place of humility. Have patience, she says, and evaluate what happened, what went wrong, and how to fix it. In interdisciplinary teams or even working with patients, the chance for miscommunication is elevated, and sometimes an apology is necessary and the right thing to do. “Own your mistakes,” Johnson says. “You don’t want to break a relationship to the point where progress fails, you can’t work together, or someone doesn’t want you as a nurse.”
Recognize the cultural communication component for each team you work on, says Johnson. “Think of how others are receiving your messaging,” she says. Nurses can also look for subtle signals in their teammates to know when the teamwork isn’t optimal. Look for body language and facial expressions, and listen to the responses from team members. “We must be proactive with talking and practice active listening,” says Johnson. “That active listening is important for gathering information, managing teams, and being team members,” she says. The skill is important enough that practicing it with role-playing is valuable.
Everett Moss II, BSN, RN, EMT-P, and a nurse anesthesia DNP candidate at the Nell Hodgson Woodruff School of Nursing at Emory University, has worked as a flight medic and nurse and as a firefighter before beginning his path to his DNP. So he understands how teamwork flows from one unit to the next in the patient’s journey. “The continuum of care is only effective with communication,” he says.
Everett Moss II is a nurse anesthesia DNP candidate at the Nell Hodgson Woodruff School of Nursing at Emory University
Every person’s role is important when a patient is moved from the ER to a trauma unit or the ICU and then is moved to discharge. “We saw that especially during COVID,” he says. Healthcare industry workers who aren’t in direct contact with patients still have a significant impact on nurses’ ability to care for patients effectively, he says. And nurses routinely communicate with pharmacies, labs, other teams, and family members or caregivers, so each step extends the team working on a patient. “In nursing, you’re forced into an environment where you have to learn teamwork or suffer the consequences of not,” he says. “And in our profession, if we suffer the consequences of not, our patients do too. I don’t believe an area of nursing survives without teamwork.”
Advanced practice degrees also provide communication skills that help nurses with teamwork, whether they remain bedside nurses or expand into other roles. As nurses progress to team leaders, David says they must understand how to lead effectively. “Understanding your style is vital in making sure you lead others,” she says, noting that she found her style and works with it. “I have a democratic approach. I tell them my expectations, but then I ask about their expectations of me. I let them know if you come to me with a concern, I want to hear a potential solution.” Building rapport strengthens trust so that each nurse can work for the betterment of the whole team. “It has to be 100 percent of the people working together,” says David.
Moss likens teamwork’s effectiveness to how sports teams operate. “Until you establish who does what, everyone may not know their role,” he says. “They may think, ‘I don’t know what you’re expecting from me, and I don’t know what to expect from you.’”
Johnson agrees. “None of us can do this alone,” she says. “The moment we do, we all fail.”
This past spring, Chenjuan Ma, PhD, and Amy Witkoski Stimpfel, PhD, RN, both assistant professors at NYU Rory Meyers College of Nursing, published a study in the Journal of Nursing Administration that examined whether working overtime can negatively influence how nurses collaborate with other nurses and physicians. In their study “The Association Between Nurse Shift Patterns and Nurse-Nurse and Nurse Physician Collaboration in Acute Care Hospital Units,” the researchers concluded that one third of all nurses work longer than they are normally scheduled, and as a result, their ability to collaborate decreases.
Drs. Ma and Stimpfel took time to talk about the study and its results.
Why did you decide to do this study in the first place?
Dr. Stimpfel: There has been increasing interest in how to manage shift work and overtime hours for nurses due to the impact of fatigue on patient safety and quality. Collaboration has been identified as being a factor that is influential in patient safety and quality as well. We know that our ability to work effectively and regulate emotions—key to collaboration—diminishes with increasing wakefulness and fatigue. We could not find literature to support the relationship between work hours/overtime and collaboration in the nursing literature, which is why we conducted this study.
It’s interesting that nurses who work regular shifts of 11.88 hours or longer regular shifts of 12.17 hours don’t have a decrease in collaboration. But if nurses working that first shift of 11.88 hours had to work a shift of 12.17 hours—which would mean overtime—they would have a decrease in collaboration. Did you discover why this happens?
Dr. Stimpfel: Our data did not detail why working overtime resulted in decreased collaboration. However, the conceptual model in our study helps guide our hypothesis about why this relationship occurs. As nurses work longer shifts, often unexpectedly, this increases wakefulness. Prolonged wakefulness can result in less ability to make decisions and regulate emotions, which may lead to greater difficulties in collaboration. As suggested by our findings, this is more likely to happen when nurses have to unexpectedly work longer than scheduled.
Does any amount of overtime cause problems with collaboration between nurses and other health care professionals?
Dr. Ma: With our current study design (i.e., observational, cross-sectional design), we were not able to detect the minimum amount required to lead to changes in collaboration. However, as the very first study of its kind, our study provided empirical evidence of a significant association between work hours/overtime and collaboration. Our current study suggested that one hour of overtime was associated with 0.17 decrease on the RN-RN scale. In other words, a 0.17 decrease from mean score of the RN-RN scale suggest that a unit’s rank on the RN-RN score would drop from 50th percentile to approximately 30th percentile.
Why is collaboration so important?
Dr. Ma: Collaboration is critical for quality care and patient safety. When working collaboratively, different parties in the patient-care team—including nurses and physicians—will share objectives, responsibility, decision making, and power to achieve patient care goals.
Previous studies have shown that patients receive superior care and have better outcomes in hospitals where nurses collaborate well with other health care providers. Without good collaboration among health care providers, quality patient care may be compromised.
Were you surprised by the results of your research?
Dr. Ma: Not really. Maybe the high number of nurses—one in three nurses—reported working longer than scheduled.
Do you have any suggestions for what should be done so that collaboration doesn’t diminish?
Dr. Ma: One highlight of our findings is the significant association between longer overtime and decreased collaboration. This finding suggests that one strategy to improve collaboration is to minimize nurse overtime as much as possible by a variety of means, better shift scheduling, and predicting and ensuring adequate staffing, etc.
Is there anything regarding this research that you think is important for readers to know?
Dr. Stimpfel: Our findings have broad implications, not just for nurses, but also for other health care providers who are at risk for shift work-related fatigue. Effective teamwork and collaboration are critical to patient outcomes, thus, managing shift work and overtime hours are important for the entire heath care team.
Any nurse knows a well-run unit has excellent staffing and dedicated workers. But such a cohesive environment also has something not so easily defined, says Dr. Jeannie Cimiotti, DNSc, RN, an associate professor at Rutgers University College of Nursing and the executive director of the New Jersey Collaborating Center for Nursing.
The key, she says, is the organization’s climate, one that supports nurses and nursing work from the top down. Because you never know what might happen on any given day, adequate staffing is important, but what really makes a nurse’s job easier isn’t always the number of patients he or she is charged with or the number of hours worked every week. Rather, says Cimiotti, it is the feeling that your colleagues have your back and that your work as a nurse is valued throughout the organization.
While many places are starting to recognize how all these factors work together, nurses have known it, and lived it, for years. When Dr. Marlene Kramer studied nursing in the 1980s, she and her colleagues found the best run medical facilities have some of the same characteristics as the top corporations. “They had good work relationships and all worked together for the good of the organization or of the patient,” Cimiotti says. Simply put, if nurses are overworked and not supported, the quality of care suffers and costs increase.
What can you do if you don’t feel supported by your organization or if, as a supervisor, you would like to see your unit operating more effectively?
Cimiotti suggests taking steps with your colleagues first and then branching out to eventually include the higher ups in your workplace. “You have to develop a culture on the unit and make sure everyone is working for the good of the patient,” she says. A supervisor can analyze satisfaction surveys and bring in the team to brainstorm ideas for improvement. Maybe patients are unhappy with something that can be easily fixed. As a staff nurse, you can bring attention to a procedure that can be done differently or follow up on a suggestion from a patient to improve care in some way.
Be sure the whole nursing team is involved including senior RNs, new nurses, LPNs, and aides. Everyone is vital to the team and when all nurses feel like their voices are being heard, they will work as a team of colleagues.
Once your unit is working cohesively, bring that to the attention of higher ups. Invite them to hear the nurses tell how they reduced their infection rate or increased the patient satisfaction surveys by several points. If you really want to get some attention, attach dollar amounts saved by new processes, because saving money while increasing patient satisfaction or being more efficient is a concrete way to show improvement.
In the end, any steps you can take to improve the organizational climate works in the favor of both nurses, who feel more supported, and patients, who receive the benefits of better quality of care.
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