Research shows that a healthy work environment can lead to more engaged nurses, decreased burnout, lower turnover and better patient care (American Association of Critical-Care Nurses, n.d.).
“It is important to create work environments in which nurses have confidence they will be heard, and actions will be taken to resolve unsafe conditions” (Ulrich et al., 2019, p. 81).
In this chapter, students will be introduced to:
- Ways that collaboration can support excellent nursing care
- Teamwork as a vital skill in nursing practice
- The impact of healthy work environments on staff and patients
This chapter emphasizes collaboration and teamwork as essential skills that keep patients safe and improve health outcomes through effective communication and respect for others. Due to the complexity of the US healthcare system, all health professions must commit to collaborative practice (NAM, 2000). Effective teams encourage members to be curious about processes, ask questions, and learn about, from and with each other to prevent errors and improve patient outcomes (AHRQ, n.d.; IPEC 2016; WHO, n.d.). Additionally, healthy work environments have been shown to positively impact staff and patient outcomes (Ulrich et. al 2019).
Collaboration
Interprofessional collaboration has gained much attention over the last two decades and nurses are being called to lead high-functioning teams that improve healthcare delivery and patient safety (IHI, 2017; Liesveld, 2017). During this era of healthcare reform, nurses are vital partners in the coordination of care (Speakman, Tagliareni et. al 2015). Due to proximity to patient care delivery, nurses have a responsibility to use knowledge from other disciplines to ensure safe, quality care, and collaborate with those professionals to prevent errors (ANA, 2010). The fragmentation and lack of collaboration in many U.S. healthcare systems lead to errors that cause patient injury and death through miscommunication (NAM, 2000). Many institutions have urged nurses to join in national efforts to reduce risk of harm and death through teamwork focused on patient-centered care (IHI, 2017; NAM, 2000; NLN, 2010; TJC, 2008, 2016; WHO, 2010).
The ANA (2010) standards of nursing practice state that registered nurses communicate effectively in all areas of practice which includes collaboration with the patient, family, and all members of the care team. The Code of Ethics states that nurses collaborate in complex systems with multiple disciplines (Fowler, 2015). However, the U.S. health system is complex with many risks for error that can cause injury or death, however, collaboration can prevent errors (NAM, 2000; TJC, 2008). Therefore, every healthcare professional must learn to bridge the gap between professional silos. This section addresses the impact that collaboration has on nursing practice and the competencies required to create effective teams.
The World Health Organization (WHO) Study Group on Interprofessional Education and Collaborative Practice (2010) developed a global Framework for Action on Interprofessional Education and Collaborative Practice. The goal is to prepare a “collaborative practice-ready” workforce for the modern healthcare system. Today’s clinicians must possess interprofessional skills that ensure seamless communication across disciplines to keep patients safe, foster quality of care, and improve patient outcomes (WHO, p. 36, 2010).
In 2000 the National Academy of Medicine estimated that 100,000 medical error deaths were caused annually (NAM, 2000). A new study found that medical error is now the THIRD leading cause of death behind heart disease and cancer with over 250,000 deaths per year (Makary and Daniel, 2016). One of the problems identified is that professions tend to work in silos rather than communicate across disciplines, so vital information can be lost when it is needed most.
A silo is a tower or pit on a farm used to store grain with the purpose of protecting the contents from contact with outside elements (https://www.merriam-webster.com/dictionary/ silo). A professional silo is “an isolated grouping, department, etc., that functions apart from others especially in a way seen as hindering communication and cooperation” (https://www.merriam-webster.com/dictionary/silo). Silos in healthcare can cause professional isolation and misunderstanding, which can lead to adverse events, injury, and death.
Definitions and scope
To collaborate means to work jointly with others, to cooperate willingly, and to “labor together” (https://www.merriam-webster.com/dictionary/collaborate). Partnering and partnership are corresponding terms that are often used in healthcare settings when referring to collaborative efforts. To partner means to join with another in a game, a dance, or a relationship for example (https://www.merriam-webster.com/dictionary/collaborate). Nurses partner with many people to provide safe, high-quality care: Patients, other nurses, interdisciplinary teams, organizational committees, and community resources. Giddens (Liesveld, 2021, p. 421) defines collaboration as “the development of partnerships to achieve best possible outcomes that reflect the particular needs of the patient, family, or community, requiring an understanding of what others have to offer.”
Nurse-patient collaboration
Perhaps the most important partnership is with the patient and family for whom all care decisions are made. As a profession, nursing has a history of being family- and patient-centered (NLN, 2010). Imagine being a family member to a patient who wants to go home, but the patient has not demonstrated proper technique on a crucial self-care skill – insulin injection. The patient is afraid and refuses to try. A nurse with expertise in lowering anxiety and health coaching arrives. This nurse partners with the patient using therapeutic communication and an attitude of teamwork. Trust is built, and the nurse presents the challenge as a game to “win.” The patient becomes engaged with a more positive attitude and successfully learns the skill. The nurse-patient collaboration helped the patient to feel that someone understood and was there as a partner in a challenging situation. The “win” was celebrated as if two tennis partners had succeeded.
During collaboration with patients and families, health literacy must be addressed – the ability to understand healthcare terms and the impact the information has on quality of life. Nurses use a form of communication called “teach back” that asks the patient to explain the health information to the nurse in the patient’s own words. This technique can point to misunderstandings and inaccuracies that could affect treatment and recovery from illness.
Nurse-nurse (intra-professional) collaboration
Nursing care for patients is rarely done alone. When nurses co-labor in teams, workloads can be shared, and morale can be boosted (Kowalski, 2015). In the example of the patient who was fearful about learning self-injection, nurses huddled to discover a solution and developed a plan of care to improve quality of life. One of the nurses had watched an expert nurse transform the experience of diabetes self-management for another patient. They agreed to temporarily cover this nurse’s workload so that this patient could be helped. The comradery in this team promotes a creative and collegial atmosphere where patient problems take center stage and are solved readily.
In another form of nurse-nurse collaboration, a novice nurse went with the expert nurse to learn nurse-patient partnership skills. Mentoring is a vital intra-professional collaborative effort that promotes retention and supports growth and development (Kowalski, 2015). In this team, the respect and support for each other’s knowledge and skills, and willingness to role model, foster professional growth and confidence in new team members. Both forms of collaboration result in high morale.
Nurse-interprofessional team collaboration
Nurses are often called to coordinate many aspects of patient care that lie outside the usual nurse responsibilities (NLN, 2010). Imagine being a family member to the patient who wants to go home, but the healthcare team has not communicated with each other regarding numerous tasks to ensure a safe discharge. Collaboration on the team has been intermittent and ineffective. A nurse with strong team skills is assigned to the case. Calls are made to departments, therapists, and providers, and processes are facilitated with an attitude of partnership. This nurse gathers the collective wisdom of each discipline to adjust the discharge plan. She then uses care coordination skills to manage the patient transition across disciplines to achieve a good outcome. The patient is now ready for discharge and thanks the nurse for stepping in.
When interprofessional teams huddle in patient care conferences, each discipline teaches, informs, guides, and advises other team members on best clinical decisions for each patient (IPEC, 2011, 2016). All relevant parties have a voice in clinical decision making, including the patient. This collaborative effort reduces error, length of stay, and cost (AHRQ, 2017). For example, the nurse reminds the team that a patient being discharged after a stroke is not able to transfer safely to the wheelchair due to medication-induced dizziness and left-sided weakness. The physical therapist agrees to teach the spouse how to assist with safe transfers and the pharmacist advises the physician about a medication with fewer side effects. The physician prescribes the new medication and discontinues the other which caused the dizziness. The patient and spouse safely demonstrate transfers the following evening. Everyone wins and the patient can be discharged to home instead of to a nursing home. The team decides that continued home care services would help the patient continue to recover so the nurse and physical therapist write detailed reports for the homecare nurse and therapist. The physician writes the prescription for these services and the patient is discharged home with a good prognosis.
Healthcare is practiced in a complex environment with frequent interruptions and multitasking so human error is inevitable (NAM, 2000). Most adverse patient events involve communication and/or teamwork failures (TJC, 2008, 2016). However, when various professions work as a team, mistakes are recognized, and errors are prevented. Effective interprofessional team members figure out how to talk with each other, so everyone remains safe – patients and staff. Because nurses spend more time in direct contact “at the bedside” than other disciplines, nurses should serve as leaders in coordination of healthcare (NAM, 2011). Nurses already work with physicians and other health professionals, but the call is to begin leading these interdisciplinary teams and nurses are in the best position to coordinate care (AHRQ, 2017; Giddens, 2021)
Nurse-organizational collaboration
Nurses are responsible for safe, quality patient care wherever they work, and they have a holistic perspective on patient needs and preferences. This knowledge is considered valuable to organizations that strive for high patient satisfaction ratings. The concept of nursing shared governance is shared decision making between the bedside nurses and nurse leaders, which includes areas such as resources, nursing research/evidence-based practice projects, new equipment purchases, and staffing. This type of shared process allows for active engagement throughout the healthcare team to promote positive patient outcomes and creates a culture of positivity and inclusion, which benefits job satisfaction (McKnight & Moore, 2022). Therefore, nurses serve on organizational committees to guide decisions on several healthcare delivery issues.
Nurse-community collaboration
Imagine being that family member of the patient who wants to go home but is unable to successfully inject the insulin. The family member would normally learn the procedure and be there each day to administer the medication, but work schedules prevent this. A referral is made to a homecare agency and the nurse then collaborates with a homecare nurse so the patient can go home. The homecare nurse can teach the willing neighbor to give the injections. This nurse-community resource collaboration ensured a safe discharge for the patient, relieved the family member of an impossible burden, and prevented extra days in the hospital.
Nurses are not only crucial in the clinical setting but can also play a key role in the community. Nurses can impact populations and communities in unique ways. When nursing informatics and evidence-based practice intersect, a variety of platforms can be created to reach those populations that may otherwise not have access to healthcare. Through applications, text-massaging, and portable monitors, patients can feel more independent, reach providers easily, and transmit data in real time (Birkley, 2017).
During times of disaster, nurses are key team members on the frontline working side-by-side with first responders and relief agencies. There are specific programs of study for post-baccalaureate degrees and certificates for nurses that wish to pursue a career in emergency and disaster management. The ANCC offers the interprofessional board certification exam for the National Healthcare Disaster Certification (NHDP-BC) for nurses. NHDP-BC nurses are experts in response, recovery, mitigation, and preparedness.
Attributes, criteria, and context in healthcare
Core competencies for collaboration were developed by the Interprofessional Education Collaborative (IPEC) Expert Panel (IPEC, 2011, 2016). The four attributes of effective interdisciplinary partnerships are: values/ethics, roles/responsibilities, communication, and teamwork/team-based practice.
To equip current and future healthcare professionals with the necessary collaborative skills, a long-term approach is needed but urgent actions are necessary now (NAM, 2001; IPEC, 2016). Team-based care can be taught through continuing education in current work settings, and health profession students can be brought together to “learn about, from, and with each other” while in school (WHO, 2010), p.13). For more information on interprofessional education and training, go to https://www.ipecollaborative.org/about-us .
Competency 1: Values/ethics
Teams that value the knowledge, skills, and perspectives of each member can communicate and problem-solve more easily. The willingness and desire to learn from each other enhances the flow of crucial patient information. Teams that work ethically have greater trust in each member’s ability to make safe, patient-centered clinical decisions.
Competency 2: Roles/responsibilities
Teams that understand each member’s roles and responsibilities can work more effectively together. For example, in a baseball team, the goal is to win the game through the expertise of each player who covers specific areas of responsibility. The catcher understands the pitcher’s role and can support that person’s work through pre-determined communication and behaviors. The outfielders understand their areas of responsibility and are ready to act immediately when needed. They also fill in for players who run to cover other bases. The team works because they have clearly defined roles, expectations, areas of responsibility, and they cover for each other when needed. In healthcare, everyone has the same goal: Safe, high-quality patient care, and great patient outcomes. The goal is achieved through many different disciplines, each member doing their part, while communicating and collaborating so “the ball is not dropped.”
Highly skilled teammates have a strong sense of professional identity and self-awareness which allows them to function in multiple roles depending on the situation (NLN, 2010). Among the many characteristics of good team players are: Adaptability, competence, dependability, enthusiasm, preparation , and tenacity (Kowalski, 2015).
Competency 3: Interprofessional communication
Communication is a vital component of effective collaboration. This skill includes the ability and willingness to listen actively, to be receptive, and act interested. Teams that value and encourage each member’s input create an atmosphere where “speaking up” is appreciated and expected. Open communication in healthcare can be the most important factor in preventing errors (NAM, 2000; TJC, 2008). Poor communication is the leading cause of healthcare errors (Makary and Daniel, 2016; TJC, 2008). Lack of communication and shared knowledge can lead to errors in clinical judgement and treatment (NAM, 2000; TJC, 2008).
To address this problem, healthcare teams can learn standardized ‘critical language’ used by aviation and nuclear energy disciplines. As an equally high-risk industry, healthcare professionals must communicate precisely and concisely, in order to react quickly during changing patient conditions (AHRQ, n.d.; Leape, 1994).
Competency 4: Teams and teamwork
As has been stated, the complexity of modern healthcare systems requires that all disciplines work together and ensure that all partners have a voice in decision-making, especially the patient (IHI, 2017; NAM, 2005; NLN, 2010). The NAM (2000) urges healthcare professionals to collaborate so that adverse events are prevented. Adverse events can occur when the wrong plan is used or when a planned action is omitted or done in a manner that causes injury or death (NAM, 2000). When more team members are alert (have their eyes on the ball), then patient safety can be ensured.
Most nurses work with professionals from other disciplines to provide care for patients. However, modern healthcare delivery tends to fragment into “professional silos” where patients are transferred from one department or facility to another. The experience can be confusing and worrisome for patients and families when professionals do not share information with each other. This lack of communication and shared knowledge can lead to errors in clinical judgement and treatment (NAM, 2000; TJC, 2008, 2016). Nurses often fill the role of team leader due to their proximity to the patient. The need for these competencies is emphasized in the Code of Ethics for Nurses (Fowler, 2015).
Collaboration can ensure that gaps are filled, and errors avoided when people work together. Through shared accountability, teams can solve problems more efficiently and be alert to potential risks. A culture of safety with high expectations for accountability encourages team members to act. Nurses who work in acute care settings must be competent in team skills due to their constant proximity to the patient. For example, nurses have knowledge about the patient that could be a determining factor in a critical decision by another discipline. A provider might order a harmful medication if the nurse did not enter the allergy in the electronic medical record. Teamwork is even more important when providing care to patients with complicated health conditions. The Joint Commission states that “safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment” (TJC, 2008, p.1).
In summary, collaboration can keep patients safe and promote good outcomes through continuous monitoring and communication by the patient, family, nurses, and all other health professionals. The shared mindset within a culture of safety builds teams that value each other, work ethically, know each other’s roles and responsibilities, communicate carefully, and find ways to work well together.
Exemplars
Nurses work in teams with patients, other nurses, and many disciplines to communicate pertinent information that enhances patient care and health outcomes. The following exemplars highlight two types of collaboration that promote healthy environments.
Mentoring
Nurse mentors are experienced individuals that either volunteer or are recommended per leadership or management to serve as a preceptor for new nurses. Nurse mentors serve as a repository of knowledge to assist new nurses acclimate to their new roles/workplace. New nurses can fall anywhere between an expert nurse and a novice nurse but are new to a facility or specialty area. New nurses are often referred to as mentees or preceptees in this dynamic. Nurse mentors must be compassionate, provide safe environments for learning, and offer support to their mentee. Often, mentees view their mentors as role models, teachers, and friends.
Diane was an experienced nurse who took a job at a new facility. She was assigned a mentor-preceptor with a well-defined role. Diane had not had experience as a mentee in this facility. The preceptor expected new nurses to take charge, care for assigned patients, and ask questions when needed, but did not explain this view to Diane. No one clarified roles and responsibilities or the expectations for new staff. Diane thought her role was to follow the preceptor to learn policies and procedures specific to this organization. Diane was reported to the nurse manager for poor performance without any prior discussion.
She was surprised when the nurse manager called her to the office to discuss the matter. When Diane explained her perception, the manager immediately clarified the roles and responsibilities of the mentor-preceptor and the mentee. This example highlights the need to communicate and clarify roles with a complete description of responsibilities.
Interprofessional education (IPE)
Interprofessional education (IPE) brings together a variety of health professions students to learn about, from, and with each other (IPEC, n.d.; WHO, 2010, p.13). Groups of students engage in interactive learning with other disciplines under the supervision of clinical faculty. These experiences prepare them for the real world of clinical practice where coordination among clinicians is an expectation (IPEC, 2011, 2016). Mutual respect for one another’s knowledge and skills increases as well.
When interdisciplinary teams work together, healthcare systems are safer and patient-centered care is improved (IPEC, 2011, 2016). IPE teaches students that collaborative practice encourages teams to be responsive to healthcare needs, practice to the full scope of expertise, share goals, and incorporate patient, family, and communities as team members. IPE experiences un-fracture the healthcare system one professional student at a time while awareness of patient safety and quality concerns are addressed.
For IPE resources, go to https://www.ipecollaborative.org/about-us
Teamwork
Imagine calling a physician about a patient who needs a dose adjustment in medication. The nurse informs the physician about the situation with a brief background that indicates why the medication order needs to be changed and makes a recommendation for the new dose. Is this overstepping the role of the nurse or is it a routine action in nursing care? Many nurses make these clinical judgments every day and work with physicians as partners in healthcare delivery.
Definition and scope
The National League for Nursing (NLN, 2010, p.28) states that teamwork appears simple, but is crucial to ensuring quality patient care and desired health outcomes. Collegiality fosters open communication, mutual respect, and shared decision making (NLN, 2010, p.30). Nurse educators are urged to prepare graduates who recognize and value their own and other’s contributions to patient care, to choose communication styles that promote teamwork, navigate conflict skillfully, and participate actively in effective team building processes. How healthcare is delivered is as important as the services provided. The NAM (2004) reports that teamwork is the most important competency for ensuring quality and safety in healthcare systems. Teamwork enhances patient care and creates a culture of collaboration where contributions from all can foster new ideas, energy, enthusiasm, and compromise (Speakman, 2017, p.57).
Attributes, criteria, and context in healthcare
A critical component to collaboration is learning to be a team player. Teamwork also involves shared accountability, shared problem solving, and shared decision-making (Giddens, 2021, p. 423). Stabler-Haas (2012, p.76) tells student nurses to think of healthcare staff as a baseball team. Each position has a unique role to play but any team member can step in at a moment’s notice to catch a ball outside the usual area of responsibility. In healthcare, laws and regulations determine scope of practice which can limit a team member’s ability to perform certain tasks, but the staff member could help by picking up an extra duty within expected professional boundaries.
Communities of practice
When teams function well, an obvious difference is felt in the work culture. Goals are well understood, and members are willing to listen and use conflict resolution when needed (Kowalski, 2015). Four attributes of a high-functioning team include:
NLN (2010) adds that supportive leadership, regular patterns of communication, cohesiveness, and mutual respect promote teamwork. The following table describes various team roles commonly found in a large urban hospital nursing unit. Some roles might not be available in smaller rural facilities.
|
Role Education |
Common Duties |
Limits |
|
Unit Personnel |
||
|
Nurse Manager BSN or master’s prepared |
RN – Licensed RN who oversees all aspects of staffing and patient care 24 hours/day, 7 days/week; Includes staffing, budget, patient acuity; delegates shift responsibilities to charge nurses; serves as front-line manager for staff hiring, evaluations, and disciplinary actions |
Practice within scope of state nurse practice act and facility policies; attends planning meetings with administration and other departments |
|
Charge Nurse BSN preferred; can be ASN |
RN – Licensed RN who oversees patient care during shift; assigns staff to patient care based on acuity and scope of practice; serves as liaison with other teams |
Can assist with patient care when needed, but is more focused on smooth running of the unit during a shift |
|
Staff Nurse Diploma, ASN, or BSN |
RN – Licensed RN responsible for all nursing care of assigned patients and families (assessment, planning, implementation, evaluation); administers medication; performs treatments; develops and adjusts individualized plan of care; delegates nursing care; monitors diagnostic results; calls providers with updates and requests for adjustments in prescriptions; makes clinical decisions regarding best care and practice; works with other departments to provide patient-centered care |
Practice within scope of state nurse practice act and facility policies; must obtain prescriptions for all patient medications, treatments, and diagnostic procedures that require a provider’s signature |
|
Licensed Practical or Vocational Nurse (LPN/LVN) Associate degree or certificate |
LPN/LVN – Licensed nurse who practices under an RN’s supervision; administers medications; performs delegated treatments; provides basic nursing care to assigned patients and families; reports all changes in patient condition to RN |
Practice within scope of state nurse practice act and facility policies; must follow individual patient care plan developed by an RN; must have a prescription for all patient medications, treatments, and diagnostics |
|
Unlicensed Assistive Personnel (UAP) High school education (plus training if CNA)
|
UAP – Unlicensed staff such as certified nursing assistants (CNA) or ‘nurse techs’ who provide basic nursing care that can be performed without a nursing license (bathing, toileting, eating, ambulation, vital signs); reports all changes in patient condition to RN |
Practice within scope of facility policies; must follow individual patient care plan developed by an RN; perform only those tasks delegated by an RN |
|
Unit Secretary/Clerk High school education |
Unlicensed staff who assists the charge nurse with smooth function of the unit; locates staff when other team members/departments call for information; answers call lights and connects patients and loved ones with RN and staff responsible for care |
Practice within scope of facility policies; does not receive prescription orders from providers |
|
Clinical Nurse Specialists (CNS) Masters prepared |
CNS - Licensed RN with graduate level expertise in a nursing specialty; often provides advice and guidance for staff RNs responsible for patient care on one or more units; meets with providers regarding medical care plans and patient outcomes; sometimes offers continuing education sessions |
Practice within scope of state nurse practice act and facility policies; in some states CNSs can prescribe medication and treatment |
|
Clinical Nurse Educator BSN or Masters prepared |
CNE – Responsible for continuing education sessions, orientations, assignment of preceptors, and training updates on mandatory skills, equipment, policies, and procedures |
Practice within scope of state nurse practice act and facility policies; maintain current fund of knowledge related to nursing care on unit |
|
Case Manager Nurses with a BSN or graduate degree; but could be a social worker |
CM – Responsible for care coordination across disciplines and with community resources for timely discharge planning; referrals for additional services such as mental health, home care, clinic referrals |
Practice within scope of state practice acts and facility policies |
|
Nursing Administration/Leadership |
||
|
Chief Nursing Officer (CNO) Or Vice President Masters or Doctoral prepared |
CNO – Licensed RN responsible for all nursing staff and patient care within a facility; Leadership and decision-making at highest levels of administration in large facilities such as hospitals |
Practice within scope of state nurse practice act and facility policies; usually does not perform patient care |
|
Director of Nursing (DON) Education varies |
DON – Licensed RN responsible for all nursing staff and patient care within a facility; Leadership and decision-making at high levels of administration such as nursing homes, agencies, community clinics |
Practice within scope of state nurse practice act and facility policies; may or may not perform patient care; education level set by facility |
|
Resource Nurse or Shift Supervisor Masters or Doctoral prepared; can be Bachelor's degree |
RN – Licensed RN responsible for staff and patient care throughout the facility during a shift; responds to crises, codes, and other emergencies; makes unit rounds to monitor care of staff and patients |
Practice within scope of state nurse practice act and facility policies; educational preparation decided by facility |
|
Other Disciplines |
||
|
Pharmacist (PharmD) Doctoral prepared Pharmacy Technician (PharmTech) Education varies |
PharmD – Licensed personnel who oversee medication dispensing to units; provide advice/ information to RNs and providers regarding drug compatibility, contraindications, and appropriateness for individual patients; attends team huddles to improve patient outcomes Pharm Techs – Unlicensed personnel who practice under the supervision of PharmDs |
Practice within scope of state pharmacist practice act and facility policies |
|
Respiratory Therapist (RT) Bachelor's degree Respiratory Therapist Assistant (RTA) Associate Degree |
RT – Licensed personnel who oversee and provide respiratory care procedures such as pulmonary hygiene, treatments, ventilator care; assess respiratory status, educate patients and families RTA – Licensed or certified personnel who practice under the supervision of an RT |
Practice within scope of state respiratory therapist practice act and facility policies |
|
Physical Therapist (DPT) Doctoral prepared Physical Therapist Assistant (PTA) Associate degree |
DPT – Licensed personnel who oversee and provide physical therapy; develop physical therapy treatment plans for individual patients; assess and evaluate progress and adjust plan of care; serve on team huddles to improve patient outcomes PTA – practice under supervision of a DPT |
Practice within scope of state physical therapist practice act and facility policies |
|
Speech Therapist (ST) Masters or doctoral prepared |
ST – Licensed personnel who oversee and provide treatment for persons with speech impairment |
Practice within scope of state speech therapist practice act and facility policies |
|
Occupational Therapist (OT) Masters or doctoral prepared |
OT – Licensed personnel who oversee and provide treatment for persons needing rehabilitation services for functional impairments |
Practice within scope of state occupational therapist practice act and facility policies |
|
Healthcare Providers with Prescriptive Authority |
||
|
Nurse Practitioner (APRN) Masters or doctoral prepared |
APRN – Nurse with an advance practice nursing license; may or may not maintain RN license; can prescribe medication and treatment and order diagnostic testing; depending on facility job description can serve in several roles |
Practice within scope of state nurse practice act and facility policies; some states require physician oversight while other states allow independent practice |
|
Physician Assistant (PA) Masters prepared |
PA – Masters prepared licensed personnel who practice under the supervision of a physician; can prescribe medication and treatment and order diagnostic testing |
Practice within scope of state physician assistant practice act and facility policies |
|
Physician Medical Doctor (MD) Osteopathic Doctor (DO) Doctoral prepared |
MD or DO – Licensed physician responsible for medical management of patients in their care; prescribe medication and treatment and order diagnostic testing |
Practice within scope of state medical practice act and facility policies |
Delegation
Registered nurses sometimes work with and supervise unlicensed assistive personnel (UAP) and Licensed Practical (or Vocational) Nurses (LPN/LVN). The UAP role is sometimes called a “Clinical Care Partner” (CCP), “Nurse Tech,” or Certified Nursing Assistant (CNA). Training for the CNA role is regulated by each state while the LPN/LVN role is accredited by organizations that oversee the education of all nurses.
The routine work of nurses on a busy unit is constantly changing, so reassignments are made, and selected tasks are handed off to staff with the knowledge and skills to complete those tasks (Murphy-Ruocco, 2015). Assignments and delegation are different. Assignments pass routine responsibilities from the nurse to another team member that falls within their scope of practice. Assignments are for work periods that include many tasks.
Delegation transfers a task from the licensed nurse to a person who verbally accepts the responsibility, possesses the knowledge and skill, and who has the legal authority to perform the task (NCSBN & ANA, 2019). The responsibility for the task lies with the people who accepted. However, the registered nurse remains accountable for the provision of care and outcome. Delegation is an essential nursing skill that benefits the team and patient.
Nurses frequently delegate nursing tasks to other non-professional workers such as unlicensed assistive personnel (UAP). UAPs are important partners in safe, quality care. As “front-line” staff, they often spend more time with patients and can observe and report crucial findings that impact patient outcomes. To foster effective teamwork, nurses must recognize and value the UAP role in team-based care (IPEC, 2011). For more information on delegation go to https://www.ncsbn.org/nursing-regulation/practice/delegation.page.
Registered nurses must learn to how delegate carefully and thoughtfully as defined by the National Council for State Boards of Nursing (NCSBN) and the American Nurses Association (ANA, 2019). National guidelines were written by these two organizations to guide safe and effective delegation from:
These guidelines do not apply to handoff reports where responsibility for patient care is transferred from RN to RN or LPN to LPN. The guidelines are intended to direct delegation of tasks that are not part of an individual’s current job description but do match the competencies of the individual who receives the delegated task. All persons who perform patient care must have validated competency to perform such tasks. Registered nurses must never delegate clinical reasoning, nursing judgment, or critical decision making but can delegate other tasks within their scope of practice (NCSBN & ANA, 2019). When nursing care is delegated, “it is imperative that the delegation process and the jurisdiction [Nurse Practice Act] be clearly understood so that it is safely, ethically and effectively carried out” (NCSBN & ANA, 2019).
The five rights of safe delegation are:
Civility in the workplace
When teamwork is practiced frequently on a nursing unit, a natural helpful environment can inspire staff to strive for excellence - individually and as a team (American Nurses Association, 2015, Scott, 2009; Stabler-Haas, 2012). Nurses and other healthcare workers automatically notice when a teammate needs assistance and step in as they ask how they can help the situation. “I can see you have a heavy load right now. My patients are all settled. How can I help? Can I take those vital signs for you and check those blood sugars?” Imagine the relief a nurse would feel with this offer when a normal assignment becomes overwhelmingly busy. Well planned routines can suddenly turn into an impossible workload when one or more patients deteriorate rapidly. The next day or week, the favor is returned and all patients on the unit are consistently well-cared for. Staff who float to the unit notice the collegiality and do not mind reassignments to the unit when help is needed. The reputation of the unit spreads, and recruitment of adequate staff is easier (Clark, 2022; RegisteredNurseRN.com, 2015; Scott, 2009; Stabler-Haas, 2012).
Not all healthcare facilities or units practice civil, helpful teamwork (Clark, 2022; RegisteredNurseRN.com, 2015). Stabler-Haas (2012) forewarns nursing students to observe team dynamics and work culture for signs of civility and incivility but not to be discouraged when witnessing a lack of teamwork. Student nurses are guests, so expressions of gratitude, dignity, and respect are required and remind staff that civility can uplift morale. Student nurses can also be helpful to busy staff by asking to help with basic tasks such as taking vital signs, providing basic comforts, helping to turn a patient in bed, and answering call lights right away (Scott, 2009).
Scott (2009, p. 33) cautions new nurses to be courageous and not let others influence them to act against best judgment. He also reminds students that intuition or “gut feelings” grow as nursing experience grows. However, defensiveness can diminish this inner knowing causing the nurse to second-guess experience. When a nurse begins to feel defensive about a clinical judgment or a much-needed criticism is offered, the nurse should stop, do a self-assessment, and look at facts. Critical feedback when done properly is a vital team skill that enhances practice and empowers everyone to strive for the best outcomes. This type of criticism helps nurses remain aware of basic principles and promotes quality and safety in the healthcare system. Being honest with each other with a coaching mindset can create high functioning teams with high morale.
It is important to end the discussion on workplace civility and incivility by referencing the mandates from the American Nurses Association and The Joint Commission. Both organizations created documents to raise awareness that incivility in healthcare settings has negative consequences. The ANA’s “Position Statement on Incivility, Bullying, and Workplace Violence” (2015) clearly states that any form of uncivil behavior is unacceptable and could place nurses and patients at risk for harm. The Joint Commission issued a sentinel alert entitled “Behaviors that undermine a culture of safety” (The Joint Commission, 2008)and called for immediate and sustained corrective action to improve safety and retain experienced staff. It is imperative that nurse leaders regularly assess workplace civility levels to inform effective workforce retention planning, implementation, and evaluation. To access ANA’s full position statement, go to https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/incivility-bullying-and-workplace-violence/
Exemplars
Civility-incivility continuum
Cynthia Clark, a nurse researcher, has studied the concept of civility for many years and continues to influence thinking that supports respect for everyone in healthcare and educational settings. Her research produced evidence-based tools, resources, and activities that support civility and foster healthy team dynamics (Clark, 2017, 2022). Her recent work focuses on authentic civility, defined as a choice to demonstrate respect, engagement, inclusivity, and connection in work relationships (Clark, et al., 2022). Clark calls for individual nurses and organizations to create cultures of civility that promote healthy work environments (Clark, 2022).
Other researchers have studied the opposite concept – incivility, and they have reported what happens when disrespectful behavior goes unchecked (Porath, 2018). Porath (2018) states that we must “put an end to the incivility bug.” Her research found that people will give more and give their best when lifted by respectful interactions. Workers are more “productive, creative, helpful, happy, and healthy” when supported by a culture of civility (Porath, 2018).
Incivility in the workplace has been a concern in healthcare organizations for some time (ANA, 2015; TJC, 2008). When the opposite of civility is tolerated, workplace bullying, harassment, and horizontal violence become a group norm. Health care workers leave, creating overloads for those who stay, and the potential for preventable medical errors increases (AACCN, 2018). The following exemplars demonstrate solutions that individuals and organizations can implement to improve communication, increase civility, and foster healthy work environments.
This video by Christine Porath (2018) describes how incivility disrupts normal functioning, fosters poor productivity, and may cause errors. The video is titled, “Why being respectful to your coworkers is good for business.” Scroll to minute seven (7) for a healthcare scenario: https://www.youtube.com/watch?v=YY1ERM-NIBY
This video by Jason Sackett (2014) teaches “effective techniques for dealing with rudeness, hostility, and uncivil behavior without becoming reactive, defensive, or submissive--and that help you keep your dignity.” The video is called “Disarming: Your key to overcoming rude and hostile behavior.” https://www.youtube.com/watch?v=C43FhOzpmHI
The need to reverse incivility in healthcare settings became so great that the Robert Wood Johnson Foundation granted funding to support the development of a “Stop the Bulling Toolkit” (PACERS, 2015). The group, known as the PACERS (Passionate About Creating an Environment of Respect and CivilitieS), aimed to stop incivility in all its forms. The kit is located on the American Nurses Association website at http://stopbullyingtoolkit.org/ and the Sigma Theta Tau International website at https://sigma.nursingrepository.org/handle/10755/616083 . This video provides an overview: Incivility and Bullying in Healthcare "Overview" Video 1 of 3
Teaching materials are organized into main themes or’ buckets’: Truth, wisdom, courage, renewal. The kit helps nurse managers to educate staff on skills that identify, intervene and prevent incivilities. The logo is a moral compass that points toward tools within each bucket:
This tool kit helps nurses to appreciate differences, and learn to:
The “Respectful conversations” training is located on the QSEN website at https://qsen.org/wp-content/uploads/formidable/Respecful-Conversations-for-Difficult-Situations-Facilitators-Guide-8.21.15.pdf
TeamSTEPPS®
To promote safety and facilitate teamwork, TeamSTEPPS®, a standardized set of critical communication skills is available through the Agency for Healthcare Research and Quality (AHRQ, n.d.). These skills were developed by the Department of Defense using communication patterns from the aviation and nuclear energy industries to ensure team safety. The healthcare industry is now benefiting as evidenced by improved patient safety. The AHRQ developed a pocket guide for quick reference on several team strategies and tools: https://www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html . Nursing programs frequently teach the following TeamSTEPPS® communication skills:
Leader: "Airway status?"
Team Member: "Airway clear"
Leader: "Breath sounds?"
Team Member: "Breath sounds decreased on right"
Leader: "Blood pressure?"
Team Member: "BP is 96/62"
For more information on TeamSTEPPs® visit the website at https://www.ahrq.gov/teamstepps/index.html
Healthy Work Environments
“A healthy nurse work environment is a workplace that is safe, empowering, and satisfying” (Wei et al., 2018). Healthy work environments have been shown to improve staff morale and patient safety (Ulrich et al, 2019). According to the American Association of Critical-Care Nurses (AACCN, n.d.) “Creating a healthy work environment (HWE) enables nurses to provide the highest standards of compassionate patient care while being fulfilled at work.” This professional nurses’ organization developed evidence-based criteria for creating healthy work environments (HWE) where staff thrive, and patient outcomes are improved (AACCN, 2019, p. 189). The standards for HWE are listed below.
1. Skilled Communication
This standard calls for nurses to become as proficient in communication skills as in clinical skills. “Skilled communication can save lives" (AACCN, n.d.). https://www.aacn.org/nursing-excellence/healthy-work-environments/skilled-communication
2. True Collaboration
Nurses are empowered to be relentless in pursuing and fostering true collaboration. “A team that works together succeeds together” (AACCN, n.d.). https://www.aacn.org/nursing-excellence/healthy-work-environments/true-collaboration
3. Effective Decision Making
Nurses are encouraged to become committed partners in making policy, directing, evaluating, and leading quality patient care (AACCN, n.d.). https://www.aacn.org/nursing-excellence/healthy-work-environments/effective-decision-making
4. Appropriate Staffing
This standard sets the expectation that patient needs are matched to nurse competencies. Appropriate staffing affects “nurse performance and retention, quality of care, patient outcomes and hospital costs [and promotes] a healthy work environment” (AACCN, n.d.) https://www.aacn.org/nursing-excellence/healthy-work-environments/appropriate-staffing
5. Meaningful Recognition
This standard calls for recognition of the value that each person brings to the organization in a way that is meaningful to that person (AACCN, n.d.). https://www.aacn.org/nursing-excellence/healthy-work-environments/meaningful-recognition
Example: A healthcare worker is recognized for his impact on a patient’s outcome. https://www.ahrq.gov/teamstepps/instructor/videos/ts_FeedbackDocToMedTech/feedbackDocToMedtech.html
6. Authentic Leadership
Fully embrace, authentically live, and engage others in promoting healthy work environments. “A good leader sets the tone for the unit" (AACCN, n.d.). https://www.aacn.org/nursing-excellence/healthy-work-environments/authentic-leadership
The AACCN website offers more information about creating healthy work environments and provides a free assessment at https://www.aacn.org/nursing-excellence/healthy-work-environments
In this chapter, students learned about:
Key Terms