"Nurse educators have an opportunity and responsibility to prepare nursing students for increasingly common team-based care settings" (Speakman, Tagliareni, Sherburne, and Sicks, p. 5, 2015).
In this chapter, students will learn:
This chapter emphasizes collaboration as an essential skill that keeps patients safe and improves health outcomes through effective communication and teamwork. Due to the complexity of the US healthcare system, all health professions must commit to collaborative practice (IOM, 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 (Scott, 2009).
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, Sherburne, and Sicks, 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 (IOM, 2000). Many institutions have urged nurses to join in national efforts to reduce the risk of harm and death through teamwork focused on patient-centered care (IHI, 2017; IOM, 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 (IOM, 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 Institute of Medicine estimated that 100,000 medical error deaths were caused annually (IOM, 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.
Silos made by Georgia Highlands College librarians using a 3-D printer
A silo is a tower or pit on a farm used to store grain to protect 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, injuries, 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.
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 the 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 the 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 the quality of life. One of the nurses had watched an expert nurse transform the experience of diabetes self-care 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). 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 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 the 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 (IOM, 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 the coordination of healthcare (IOM, 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, p. 441, 2017)
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. 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; however, work schedules prevent this solution. The nurse then collaborates with a homecare agency so the patient can go home. A referral is made so a 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.
Attributes, criteria, and context in healthcare
Core competencies for collaboration were developed by the Interprofessional Education Collaborative (IPEC) Expert Panel (IPEC, 2011). The four attributes of effective interdisciplinary partnerships are values/ethics, roles/responsibilities, communication, and teamwork/team-based practice.
IPE Core Competencies. Source: IPEC, 2011
To equip current and future healthcare professionals with the necessary collaborative skills, a long-term approach is needed but urgent actions are necessary now (IOM, 2001; IPEC, 2016). Team-base 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, p. 13, 2010). For more information on interprofessional education and training, go to https://nebula.wsimg.com/3ee8a4b5b5f7ab794c742b14601d5f23 ?AccessKeyId=DC06780E69ED19E2B3A5&disposition=0&alloworigin=1.
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 adaptable, competent, dependable, enthusiastic, prepared, and tenacious (Kowalski, 2015).
Competency 3: 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 and create an atmosphere where speaking up is appreciated and expected. Open communication in healthcare can be the most important factor in preventing error (IOM, 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 judgment and treatment (IOM, 2000; TJC, 2008).
To address this problem, healthcare teams can learn a 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: Teamwork/team-based practice
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; IOM, 2005; NLN, 2010). The IOM (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 (IOM, 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 judgment and treatment (IOM, 2000; TJC, 2008, 2016). Nurses often fill the role of team coordination 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 patients that could be determining factors 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, p. 1, 2008).
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
Diane was an experienced nurse who took a job at a new facility. She was assigned to a mentor-preceptor with a well-defined role. The preceptor expected new nurses to take charge, care for assigned patients, and ask questions when needed, but she 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 collaborative practice drives safe, high-quality, accessible, person-centered care and improved population health outcomes” (https://www.ipecollaborative.org/vision---mission.html).
Interprofessional education (IPE) brings health professions students together to learn about, from, and with each other (WHO, p. 13, 2010). 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). Mutual respect for one another’s knowledge and skills increases. When interdisciplinary teams work together, healthcare systems are safer and patient-centered care is improved (IPEC, 2011). 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 more information on the IPEC go to https://www.ipecollaborative.org/resources.html.
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, p. 28, 2010) 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, p. 30, 2010). 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 IOM (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, p. 53, 2017).
Attributes, criteria, and context in healthcare
Stabler-Haas (p. 76, 2012) tells student nurses to think of healthcare staff like 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 the 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.
|
BOX With a continuum for teamwork and “communities of practice” <<<<<<<Solo……..one helper……nurse team…….IP team>>>>>>>>>>> Limited view for decisions <<<<<<<<<<>>>>>>>>>>>>>>multiple views to inform decisions |
Note: Communities of practice created by the authors
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 communications, 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 |
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 the scope of state nurse practice act and facility policies; attends planning meetings with administration and other departments |
|
Charge Nurse BSN preferred |
RN – Licensed RN who oversees patient care during the shift; BSN is preferred; assigns patient care to staff based on acuity and scope of practice; liaison with other teams |
Can assist with patient care when needed, but is more focused on the 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); administer medication; perform treatments; develop and adjust individualized plan of care; delegate nursing care; monitor diagnostic results; call providers with updates and requests for adjustments in prescriptions; make clinical decisions regarding best care and practice; work with other departments to provide patient-centered care |
Practice within the scope of state nurse practice act and facility policies; must obtain prescriptions for all patient medications, treatments, and diagnostic procedures |
|
Licensed Practical or Vocational Nurse (LPN/LVN) |
LPN/LVN – Licensed nurse who practices under an RN’s supervision; administer medications; perform delegated treatments; provide basic nursing care to assigned patients and families; report all changes in patient condition to RN |
Practice within the 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) |
UAP – Unlicensed staff such as certified nursing assistants (CNA) or nurse techs who provide basic nursing care which can be performed without a nursing license (bathing, toileting, eating, ambulation, vital signs); report all changes in patient condition to RN |
Practice within the 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 |
Unlicensed staff who assists the charge nurse with smooth function of the unit; locates staff when other team members/departments call for information; connects loved ones with RN responsible for care; answers call lights and connects patients with staff responsible for care |
Practice within the scope of facility policies; cannot 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 plans and patient outcomes; sometimes offers continuing education sessions |
Practice within the 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 |
Responsible for on-unit continuing education sessions, clinical updates on mandatory skills, equipment, policies, and procedures, assignment of preceptors, and orientation of new staff |
Practice within the scope of state nurse practice act and facility policies; maintain current fund of knowledge related to nursing care on the unit |
|
Case Manager either nurse with a BSN or graduate degree OR social worker |
Responsible for care coordination across disciplines and with community resources for timely discharge planning; referrals for additional services such as mental health |
Practice within the scope of state practice acts and facility policies; |
|
Nursing Administration/Leadership |
||
|
Chief Nursing Officer (CNO) 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 |
Practice within the scope of state nurse practice act and facility policies; Usually does not perform patient care |
|
Resource Nurse or Shift Supervisor Masters or Doctoral prepared |
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 the care of staff and patients |
Practice within the scope of state nurse practice act and facility policies; |
|
Other Disciplines |
||
|
Pharmacist (PharmD) Pharmacy Technician Doctoral prepared |
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 the scope of state pharmacist practice act and facility policies |
|
Respiratory Therapist (RT) Baccalaureate 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 the 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 the plan of care; serve on team huddles to improve patient outcomes PTA – practice under the supervision of a DPT |
Practice within the scope of state physical therapy 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 the scope of state speech therapy 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 the scope of state occupational therapy practice act and facility policies |
|
Healthcare Providers with Prescriptive Authority |
||
|
Nurse Practitioner (APRN) Masters or doctoral prepared |
APRN – Nurse with an advanced 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 the 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 the 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 the 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 and ANA, 2019). The responsibility for the task lies with the persons 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/NGND-PosPaper_06.pdf.
Registered nurses must learn how to 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. They are intended to guide the delegation of tasks that are not part of the current job description but do match the competencies of the person who receives the delegation. 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 and 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 and ANA, 2019).
The five rights of safe delegation are:
Civility in the workplace
When teamwork is practiced frequently in a nursing unit, a natural helpful environment can inspire staff to strive for excellence - individually and as a team (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 being reassigned to the unit when help is needed. The reputation of the unit spreads, and the recruitment of adequate staff is easier (Scott, 2009; Stabler-Haas, 2012).
Scott (2009) describes the benefits of civil teamwork: Maximization of problem-solving ideas, promotion of role-modeling, fine-tuning of work practices, reduction of staff injuries, efficient time-management, and improved customer service experience for patients and loved ones. He also points to the consequences of failed teamwork or incivility: lack of observation, injuries, lower morale, and changed attitudes that lower the quality of care (Porath, 2016; Scott, p. 53-4, 2009).
Not all healthcare facilities or units practice civil, helpful teamwork. 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 not only required but also bring a reminder to 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 (p. 33, 2009) 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. Nurse leaders must 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/work-environment/violence-incivility-bullying/.
Exemplars
Our society has noticed what happens when incivility goes unchecked (Porath, 2016). Workplace bullying, harassment, and horizontal violence is tolerated and becomes a group norm. Health care workers leave, creating overloads for those who stay, and the potential for preventable medical errors increases.
TeamSTEPPS
The AHRQ (n.d.) emphasizes the importance of cross-disciplinary care coordination to promote safety and quality. To facilitate team efforts, a standardized set of critical communication skills were developed.
These skills were developed by the Department of Defense and were informed by communication patterns used in the aviation and nuclear energy industries to ensure team safety. The healthcare industry is now using these skills to improve patient safety (AHRQ, n.d.).
PACERS
Incivility in the workplace has become a concern in healthcare organizations (ANA, 2015; TJC, 2008). The need became so great that the Robert Wood Johnson Foundation provided a grant to support nurse leaders in the development of the Stop the Bullying Toolkit (PACERS, 2015). The group, known as the PACERS (Passionate About Creating an Environment of Respect and CivilitieS), hopes to stop incivility in all its forms.
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 kits helps nurses to appreciate differences, and learn to:
In this chapter, students learned about: