Posted: July 7th, 2023

Clinical simulation: Health care providers

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CHAPTER 9 Team Communication

For the purpose of this text, we are going to use the following as working definitions:

■ Clinical simulation: Health care providers (students and/or professionals) role-playing scripted scenarios to enhance clinical care, health commu- nication, and reduce provider stress; may include a student/professional, or paid actors or can be done with a computerized mannequin

■ Communication climate: The atmosphere, environment, and/or conditions that impact small-group/team communication; can be positive, neutral, or negative

■ Norms: Rules or standards groups/teams use to communicate what behaviors are acceptable, expected, and/or unacceptable

■ Small-group/team communication: Three to 20 individuals working together interdependently to accomplish common goals; 13 is thought to be the ideal number for a small group/team

■ Social exchange theory: Explains group/team behavior in terms of positives and negative relationships and rewards

■ Symbolic convergence theory: Posits that communication helps inform and construct a group/team’s culture as well its communication behaviors and decision making

■ Systems theory: Describes group/team as a system that uses information from a variety of sources, internal and external, to process, analyze, and act on that information in order to attain a desired outcome or goal

■ Team climate: The environment/feeling that members create and promote vis-à-vis their communication behaviors (can be positive/supportive or negative/defensive)

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■ T E A M C O M M U N I C A T I O N I N H O S P I T A L S / H E A L T H C A R E

As we have previously discussed, especially in hospitals and acute care facilities, 21st-century American health care is much more team focused than individ- ualized. It should be noted that for the purpose of this book, the term team communication is used, but in reality, that term is readily exchangeable with small-group communication. Also, although most organizations today are team oriented, health care delivery systems, especially hospitals, have very diverse members who are patient-centered stakeholders (employees, contractors, con- sultants, etc.) and may not all be employed members of the same organization (but functioning as such). For example, it is not uncommon in many emergency departments (EDs) today for the physicians, physician assistants, and advanced practice nurses to not be hospital employees, but rather contracted labor from an emergency medicine group (e.g., Emergency Medicine Physicians [EMP] in Canton, Ohio). Similarly, because EMP, like all contractors, may not be able to find enough ED providers in a particular city to staff a particular contracted hos- pital, EMP may use “fire fighters,” ED providers from other cities who are sent to a particular hospital for protracted periods of time (locum tenens), usually weeks or months. Therefore, the critically important ED team of MD/DO (doctor of osteopathy), RN, physician assis tant (PA), advanced practice registered nurse (APRN), and technicians who are required for effective emergency care often may be comprised of members who are not employed by the same institution. In addition, because of staffing needs (24/7/365), hospital teams, ED and others, frequently include members who are interchangeable (recall our discussion of hiring/staffing, standardized and replaceable members for organizational suc- cess), for example, the scrub nurse for a hip replacement in the morning will almost certainly be different for the same procedure, even the same surgeon that night. This need for teams and interdependent behaviors that coalesce into successful outcomes is a key element of differentiation between team member- ship in hospital-styled institutions and other nonhospital-type organizations.

Reflection 9.1. Think about a nonhospital team/group you have been or are a member of. What would be the impact on the team’s goals if tomorrow someone with the same skills suddenly replaced one member? And then 2 days later, the original member returns, but now a different member is replaced? How would you expect these changes to impact the team’s process, production, communication, time management, and outcomes? Why?

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As you can see, the use of teams in hospitals (and hospital-like entities, hospices, rehabilitation centers, long-term care facilities, etc.) is both crit- ical to the organization’s goals, but also to safe and effective patient care. In most nonhospital-like organizations (corporate, for profit, nonprofit, etc.), teams are created based on the team’s role/goals, and careful atten- tion is paid to the individual potential contributions to the team’s efforts by specific employees. In hospitals, teams are used to maximize health care delivery, provide “checks and balances” in the assessment of decisions, plans, and behaviors/actions. For example, in a typical acute-care hospital there are likely surgical, medical, obstetrics, and pediatrics units that care for inpatients 24/7/365. In many hospitals today, such a unit would utilize a team approach to patient care that at the very least would include one or more of the following members:

■ RNs (usually discipline specific, medicine vs. surgery, etc.)

■ MD/DOs (almost always discipline specific, board certified in surgery vs. pediatrics), patient’s private doctor versus hospitalist

■ Licensed practical nurses (LPNs; nurses who work under the supervision of RNs and are usually less discipline specific)

■ PAs or APRNs (usually discipline specific, but may be more generalist than MD/DO; work under the supervision of the private, or hospitalist, MD/DO)

■ Residents (MD/DO, discipline specific, but of varying years of experience, usually 1–5 years post-MD/DO degree)

■ Students (RN, APRN, PA, at various stages of their education/clinical training and available for different periods of time, from 1 day a week or less, to an entire 6–8 weeks)

■ Technicians/nursing assistants (may be unit specific or may float between units/disciplines as needed)

As you can quickly see, a team for one unit of a hospital can have anywhere from seven to 10 or more team members, especially if there are private doctors on the team, students, and so forth. But again, the distinction here is that the makeup of that team—from a professional per- spective—may be constant, one of each from the previous list, but the indi- vidual—physician, RN, PA, resident, and so forth—will likely change not just daily, but two or three times per day (depending on whether staffing is on 8- or 12-hour shifts). Consequently, if you worked at Ford or Apple, or any other major organization in America and you were placed on a team, in all likelihood the makeup of that team would be static because stability is expected to benefit from the predictability of the team individually and collectively. And, in many organizations, the specific members of teams are maintained for months, if not years. However, in health care there is hardly a portion of a day that goes by without the health care team hav- ing different individuals rotate through. Therefore, the dialectical tension

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between the need to work together but with a variety of regularly changing team members, underlies the critical importance of effective interpersonal and team communication.

The use of teams in hospitals is both vital to successful health care delivery as well as to overall organizational goal attainment. Teams help health care organizations accomplish numerous goals by (a) increasing diverse input into analysis and decision making; (b) offering interdisciplinary/interprofessional approaches; and (c) providing more opportunities for explorations of ideas, assessments, interventions, and plans. This modern approach to health care delivery is far different than the physician-centric model that was the norm for thousands of years. From ancient Egypt to the late 20th century, health care delivery was primarily the purview of physicians who diagnosed and treated patients. However, this physician-focused method did not utilize a team approach to patient care, but frequently relied on nonphysicians (usually nurses) to dutifully carry out the physician’s orders/instructions/prescriptions. But with the introduction of midlevel providers (certified registered nurse anesthetists [CRNA], PAs, APRNs, etc.), evolving RN roles, economic consid- erations, and managed care—hospitals and health care providers have reori- ented their approaches to patient care to follow a more collaborative, diverse, and inclusive team model.

With the ever-increasing quantities of wellness/illness/injury knowledge, technology development, treatment options, and health care costs it is critical for hospitals to find an organizational communication approach to patient care that can adapt quickly and effectively. Consequently, interprofessional teams have evolved as the primary method most institutions use to accomplish clin- ical/patient goals, enhance health care delivery, and overcome risks. Unlike nonhospital organizations, hospitals’ health care goals and patient needs/ expectations require teams to be constantly working to assess and resolve the daily patient–provider task, problem, and/or solution issues that exist 24/7/365 in modern hospitals. And, unlike many organizations that are not even open 24/7/365, hospitals need teams (of administrators and providers) to develop policies and procedures for the daily care of patients, but also regarding:

■ How to handle a catastrophic event with dozens or more injured

■ Outbreaks of rare contagious diseases

■ Shortening wait times in the ED

■ Increasing the arrival time of the code team at a dying patient’s bedside

Therefore, the value of patient care teams to the organization’s success and goal attainment is only overshadowed by the importance of countless teams’ efforts in almost every aspect of a hospital’s daily health care deliv- ery process. In order for hospitals to utilize their staff and facilities most effectively they must rely on diverse health care providers, each with his or her professional input, analysis, and critical thinking, contributing to teams that often have interchangeable members from the same profession.

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This consistent, dialectical tension between needing a particular discipline represented on a team, but not being able to control which professional is working on the team on any given day is truly unique to hospital-like institutions. Therefore, it should not be surprising to recognize the need for effective interpersonal and team communication in order to accomplish a hospital team’s goals and objectives—in spite of the lack of individual pre- dictability of members.

Let’s examine just one potential problem for a health care team that is constructed with specific professional members (physician, nurse, resident, midlevel provider, etc.), but on any given day (or at any given meeting time) the members could be all the same as previously, or they could all be com- pletely different. For example, Sara is Mr. Jones’s surgeon, she makes rounds (sees her patients) with her PA, Molly; Mr. Jones’s 7:00 a.m. to 3:00 p.m. RN, Jim; the surgical residents, Frank, Mary, and Miles; and two nursing students, Hillary and Betty. These eight providers go to the patient’s bedside, talk and/ or listen to the conversation with the patient, observe the dressing change, and discuss the treatment plan for the day. At 8:00 p.m., the same day, Cathy is the RN caring for Mr. Jones who has spiked an oral temperature of 101.6°F and is complaining of increased pain around his wound. Cathy did not see the patient at morning rounds, or talk with any of the team—except Jim at shift change. Jim provided his usual hand off—situation, background, assessment, and recommendation (SBAR)—for each of the patients he was turning over to Cathy. Therefore, Cathy knew from Mr. Jones’s SBAR, as well as her review of his electronic medical record (EMR), that he did not complain of pain, or have a fever earlier in the day. She also knows that although there is an order for an antipyretic, acetaminophen (to lower his temperature), fever and pain in a postoperative patient are often indicative of more serious wound or lung infections that need to be assessed. Consequently, Cathy gets the patient’s pre- scribed medication, but also telephones Molly, Dr. Jones’s PA, as well as Henry, the surgical resident on duty. Molly asks Cathy to have Henry call her after he examines the patient. Molly tells Cathy that although she is on call that night, Dr. Watt is covering for Dr. Jones and Molly will make Dr. Watt aware of the situation as soon as she hears back from Henry, but in the meantime to please call if Mr. Jones gets worse, if Cathy has any questions, or Henry cannot come see the patient soon.

This example illustrates just one aspect of the onerous nature of 21st- century health care in America. Although teams are used to improve patient care and reduce risks, the members of these teams cannot function 24/7/365. Therefore, hospital teams not only have to work as cohesive, collaborative units, but do so with interchangeable members whose professional education and experiences are similar—even though their identities and backgrounds are clearly disparate. Originally, there are eight providers from diverse professions who are function- ing as a task-oriented, problem-solving, and decision-making team. However, 12 hours later, none of the original eight team members are in the hospital, let alone available to meet and assess the patient’s problem and derive a solution.

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But because of the communication, education, and team processes utilized in hospitals and hospital-like facilities, the different team members at 8:00 p.m. functioned in many ways like the earlier team. First, Cathy used the informa- tion from her peer, Jim, to understand the patient’s condition, but she also used the morning team’s assessment and plan from the EMR. Second, when Mr. Jones’s health changed, based on the data Cathy was given (verbally and in writing, as well as her own assessment of the patient), she fulfilled her team role and responsibilities by first providing medication that was ordered. Third, she also notified the appropriate (based on the team structure and ver- tical hierarchy) team members of the change in the patient’s signs (fever) and symptoms (peri-wound pain). This new, but consistent health care team must now focus on problem solving with certain members, surgical resident, RN, PA, and eventually the oncall surgeon to work collaboratively and interde- pendently to assess the problem, identify the cause, and find the most effec- tive solution. In order for this to occur, Cathy needs to both assess the patient as well as communicate with Henry, the surgical resident. Once Henry has assimilated Cathy’s information, with his own patient assessment, he will need to communicate that by phone to Molly. Based on Cathy and Henry’s find- ings and Henry’s recommendations, Molly will need to determine if there is a need for her to examine the patient, order further tests, or contact Dr. Watt. At every stage of this problem-solving process information is expanded vis-à-vis input from multiple sources with diverse health education and experiences all contributing to the analysis and decision making. As current or future health care providers/professionals, you need to understand how these teams func- tion, what makes one team more effective than another, and how to address conflict and/or communication problems. Furthermore, although the previous examples are hospital/hospital-like institution specific, please recognize that private practice offices, public/community health clinics, stand-alone urgent care facilities, and so forth all use team communication to accomplish their organizational and patient care goals.

■ A S Y S T E M S A P P R O A C H

Although there are a number of small-group/team communication theories, we are going to focus on systems theory. Clearly, health care team com- munication can be viewed using a variety of theoretical lenses, including social exchange theory and symbolic convergence theory, as well as others (structuration, functional, etc.). However, for the purposes of this text a sys- tems approach seems to be the most appropriate (and some would argue the most common approach regardless of organizational type, goals, etc.). Systems theory views team communication as a group of subsystems, with each member (subsystem) of the team providing different skills, knowledge, expertise, and input to help attain team/organizational goals. As you can tell, systems theory is about skilled individuals, in our case, health professionals

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working together to accomplish tasks, solve problems, make decisions, and so forth. For health care teams, this interprofessional approach heightens the interdependent possibilities for exploring diverse viewpoints, opportuni- ties, analyses, and solutions/plans. Furthermore, a systems-theory approach would suggest that the more health care teams function interdependently to gather information (from the patient, objective data [vital signs, labs/tests, procedures], other providers, scholarly literature, etc.) and analyze it from diverse professional perspectives, the more likely they will be to effectively address problems, develop (and when necessary revise) solutions/treatment plans, and enhance decision making with the patient. However, success- ful outcomes/goal attainments are dependent on a number of key com- munication factors related to team development: roles, norms, status, and relationships.

■ T E A M D E V E L O P M E N T

As previously noted, health care teams are unique in many ways; however, members of such teams are generally first hired related to their profession, certification licensures, and so forth. In fact, most hospital hiring is still done in professions—independent of the interdisciplinary team structure that most hospital providers are expected to work in. Consequently, nurses are hired by nurses, physicians and physician assistants by physicians, and so forth. In some non health care organizations in which a person is being hired to function primarily as part of a team, that applicant likely would be inter- viewed and assessed by one or more members of the team he or she would be working with, as well as his or her department/unit/organization manager/ supervisor.

Reflection 9.2. Can you recall a team you were a member of—sports, academic, or professional—how did you work interdependently to accomplish the team’s goals? What made that team different from others that were not as successful?

Because of the independent nature of 21st-century health care regarding professional identity, hospital teams are often developed—not through a primary team focus (interprofessional)—but intraprofessionally, with pro- fessional peers making the hiring decisions. However, soon after a hospital

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provider is hired, he or she is expected to work in a number of intra- and interprofessional teams. For example, physicians (as well as residents) are expected to work with other MDs to assure coverage/staffing, policy and procedural regulations, effective patient care, as well as peer review in con- flict situations. This same approach is true in nursing. However, PAs—who by law must be supervised by physicians—are viewed as part of the physi- cian intraprofessional team, not nursing. APRNs may be hired under either the nursing or physician intraprofessional team. Consequently, the mem- bers of countless health care teams seldom have any relationship with the other providers in their interprofessional team until they meet as part of their work experience. Therefore, if you go to work for a hospital, intrapro- fessional peers who are not part of your interprofessional teams will likely hire you.

If you recall our previous examples, the patient had a specific physician; however, that physician may have someone else covering for him/her at night, on weekends, vacations, or holidays. Similarly, the patient will likely receive care from a minimum of two different nurses each day, but they can be dif- ferent from one day to the next. This unique team approach, which does not include specific members but rather interchangeable profession-dependent individuals, creates a major need for effective team communication and role identity.

■ R O L E S

Health care roles, especially in hospitals, are clearly defined, therefore, certain members can order treatments, others carry out those orders, some members can work in surgery, or labor and delivery, and so forth; these roles are gen- erally codified vis-à-vis a member’s academic degree and state licensure. Consequently, an RN’s role is related to but distinct from a PA, MD, certi- fied nursing assistant (CNA), and so forth. The benefit for unique health care teams—in some situations teams are formed and dissolved on a daily basis—is that there is no time spent questioning a member’s role. In health care generally provider’s roles are clearly defined, regulated, and communicated. Therefore, the RN who starts a shift at 7:00 a.m. expects the intraprofessional team to be other RNs who are both educated and licensed as he or she is. Similarly, the RN expects the members of the interprofessional teams to be comprised of providers who have been assigned, like herself or himself, to the care of a particular patient. Therefore, the team may be patient centered and the RN may very well have a different team for each of her patients on any given day. This same reality is true for the other professional members of a hospital team. The obstetrician–physician who has a patient in labor may have worked with some of the RNs who are caring for the patient, but he or she may not know the CRNA, or the scrub nurse, neonatal APRN, and so forth if a caesarean sec- tion (c-section) is required.

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The critical importance of having clearly identifiable and highly codifed roles is one of the major reasons why health care teams are so effective. The team members generally assume each other’s credibility and capability, based on a person’s academic degree, title, and license. However, successful teamwork, goal attainment, and/or patient outcomes do not happen automatically based on members’ roles. Teams need to collaborate, fully participate, and effectively communicate and that doesn’t just rely on roles, but also on clearly understood team norms.

■ N O R M S

Teams need norms in order to assure that everyone understands, not just his or her professional, but intrateam goals. For example, one health care team norm might be that no one uses his or her status to insult or demean anyone on the team. A typical norm, as we have seen in prior examples, is that the team in a hospital unit understands that its members will all meet— regardless of who the individuals are, to review the patient’s progress, address any issues, and work with the patient to determine a plan for next steps. Consequently, for one team, the norm might be to “make rounds” at 6:30 a.m., whereas a different team might do its patient visits starting at 7:00 a.m. Other norms may be focused on who starts the presentation, or who examines the patient first, and so forth. These norms are not static and my change based on mem- bers or context within an interprofessional team, but almost surely will have some variances across all intra- and interprofessional teams. Therefore, it would be expected that norms for an inter- and intraprofessional team would be different when making rounds than in surgery, or the delivery room, and so forth. Clearly, providers need to recognize that like roles, norms need to be communicated and understood, but unlike roles, norms are context and intra- and/or interprofessional team dependent. However, just as norms are critical for effective team communication, so too is understanding how status differences impact team communication.

Reflection 9.3. How do you think the clarity of role distinctions in health care teams might enhance and/or diminish effective interprofessional communica- tion? Why?

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■ S T A T U S

In health care organizations, especially hospitals, status is frequently deter- mined and/or perceived based on members’ titles: CEO, chief nursing officer (CNO), director, manager, and so forth for administrators and by academic degrees/licenses: MD/DO, RN, APRN, PA, and so forth for providers/ clinicians. And even though providers may have the same degree, board certi- fication, and license, there are often status distinctions within intraprofessional teams. For example, some members may have higher status among peers based on research, publications, professional reputation, clinical skills, and so forth. However, status can have even more of a profound impact on interprofessional teams and their communication behaviors.

Because for centuries health care has afforded higher status to physicians than other health care providers—especially when it came to patient care decision making, it is only recently that status among interprofessional team members has been questioned and/or considered. However, we know a num- ber of important realities about the role of status in group/team communica- tion (regardless of the organization—health care related or not), including:

1. Just as in patient–provider communication, the interprofessional team members with higher status can be expected to speak more than those with lower status.

2. High-status interprofessional members can be expected to communi- cate more intraprofessionally, than interprofessionally (e.g., MDs/DOs and residents, or RNs and APRNs).

3. Interprofessional members who perceive their status to be lower than other members generally communicate more positively to higher status teammates than to their equals or lower status members.

4. Team members may focus on and/or more frequently accept high-status members’ suggestions over lower status members’ analyses and recommendations.

Reflection 9.4. Can you recall some norms, stated or understood, for a team you were a member of? How did these norms aid or detract from effective communication and/or goal attainment? Why?

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As you can see there are some very serious status consequences for interprofessional health care teams unless they recognize the risks early and discuss how they can both address the status realities and minimize the potential information sharing, tasks, and/or decision-making difficulties related to them.

Reflection 9.5. Have you worked in a group/team in which one or more members had a higher status than you? If so, how did it impact your group/ team communication? If not, what are your views of the issues listed previously in terms of status differences?

Therefore, based on the possible impact of status differences in interpro- fessional health care teams, there needs to be a communication strategy for members to use to avoid, or at least limit, these negative effects. If members recognize how higher status individuals tend to dominate conversations, then the team might want to have an appointed discussion leader who does not have the highest status and who is empowered to assure equal input in discussions. For example, an interdisciplinary hospice team might use an RN, social worker, or chaplain to lead its meetings and while needing and encouraging input from physicians, nurses, and others, the discussion leader would make every effort to give equal time and opportunity to all profession- als on the team. Similarly, the team might agree on a norm that discourages “sidebar” conversations intra- and interprofessionally in order to minimize both the distractions, but also to limit similar-status members communi- cating with each other instead of with the team. Furthermore, teams might want to try to prevent other status issues by agreeing on norms that dis- courage members from using “group think” communication and agreeing to what others have proposed related to status differences. Similarly, encourage members, regardless of status, to be honest with the team when commu- nicating their viewpoints. It will not serve the interprofessional team well if lower status members are not communicating their perspectives with everyone. Separate conversations with perceived equal and/or lower status team members during which different views are expressed than those stated with higher status teammates can only serve to minimize the diversity of input into the team’s decision making, but also negatively impact the team’s dynamics and culture by lowering morale. Interprofessional teams need to

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both understand and address the issues related to roles, norms, and status if they are to develop trusting relationships and effective interprofessional team communication.

■ R E L A T I O N S H I P S

In order to enhance interprofessional health care teams, it is important to focus on interpersonal communication. Even though teams function as a collective, at their core, most teams are greatly impacted by interpersonal communication in order for members to develop professional interpersonal relationships. And as we have discussed previously, Americans often trust and prefer to work with others who are similar to themselves. The same can be expected in health care teams; however, by their very nature, these interprofessional teams are diverse in a number of key areas:

■ Profession

■ Health care experience

■ Age

■ Sex

■ Status

Consequently, interprofessional health care teams must rely on members’ efforts to develop professional relationships that will help them overcome their differences, increase trust, and use that diversity to enhance group out- comes. In fact, the diverse nature as well as interchangeable aspect of inter- professional health care teams affords them great opportunities. For example, when providers work independently, an MD/DO/PA/APRN sees a patient in the hospital, writes orders and moves on to the next patient, procedure, office, and so forth. Then the RN is expected to read the orders and carry them out, often with little or no input or discussion about the patient’s history since the last time the patient was seen by the provider writing the orders. In addition, the RN does not generally have any explanation for why one treatment plan is being used versus another and no easy way to communicate issues that the RN wants to discuss. Therefore, the patient’s care and deci- sion making are being negatively impacted by the lack of information sharing and diverse input. Also, the lack of face-to-face communication and/or infor- mation sharing among various professionals who are caring for the patient, further risks miscommunication and/or missing data. Going back 20 years or more, hospital health care roles were very rigid and resulted in a more linear and authoritarian approach to communication and decision making. In that era, an MD independently did “X,” and RNs and other non-MDs followed his or her orders/decisions. However, it has been demonstrated through health care risk management, quality control, and organizational communication

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that everyone benefits from a diverse interprofessional team approach to information exchanges and patient care. Although it is true that the MD/DO is ultimately responsible for the decisions and hospital orders—that legal reality can be enhanced by interprofessional health care teams that use interpersonal communication to develop trusting relationships and minimize the authori- tarian nature of decision making and encourage a much more collaborative, participative team approach that benefits from the team members’ diversity, input, and critical thinking. However, health care team members have spe- cific administrative and/or clinical roles, but in addition, teams generally have members who take on specific team roles.

■ T E A M R O L E S

Just as it is important for team members to understand each other’s profes- sional roles, it is very helpful to recognize the various team roles that members may assume. In fact, Benne and Sheats (1948) created a list of possible team roles that members may utilize, including:

■ Aggressor

■ Blocker

■ Recognition seeker

■ Joker

■ Dominator

These various team roles are generally recognizable to anyone who has been a part of any type of team, from our families, to sports teams, to health care teams. It is important for interprofessional teams to understand that in addition to, or in some cases related to, a member’s clinical or administra- tive role, he or she may use the role to impact team dynamics and commu- nication exchanges. As you know from your experiences in groups/teams, these roles can be beneficial to the overall goals of the members. However, some of these roles can create trust and relationship development prob- lems within the team. Therefore, interprofessional health care teams have to recognize when members are using one of these roles in an effort to thwart interaction, information sharing, collaboration, and/or participation. For example, a joker can be a helpful role in a team—as long as the member is not using humor as a way to block discussions. However, once an individ- ual member assumes one of these roles, the team must be willing to address the issue of how it impacts, positively or negatively, the team’s tasks, goals, and dynamics. This ability to identify potential team problems is critically important, but also must be viewed in the context of positive versus negative team conflict.

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172 Health Communication for Health Care Professionals

■ M A N A G I N G C O N F L I C T

First and foremost, it is important to recognize that conflict, in and of itself, is not a bad thing. Conflict is basically a disagreement, but in terms of com- munication and decision making, disagreements are opportunities to explore other ideas, approaches, and viewpoints. One of the benefits of interpro- fessional health care teams that we have been discussing is the impor- tance of members’ diversity. However, the benefits of members’ uniqueness (professional, role, age, etc.) lies in their abilities to provide a variety of dif- ferent contributions to whatever topic, role, task, or goal the team is working on. As mentioned previously, team think is the opposite of conflict. Team think occurs when members just agree with whatever is being proposed, rather than offering conflicting views, ideas, or alternatives. Consider a team in which everyone just agrees with one member’s recommendations (team think) without debate and consideration of other options—consequently, the possibilities that the unspoken, unconsidered, and unanalyzed alterna- tives might have resulted in a better outcome are unknown. Also, recognize that without conflict, teams would really have nothing to discuss and no real purpose. However, although team conflict is both necessary and positive for exploring diverse options for completing tasks, addressing/solving problems, and accomplishing goals, some forms of team conflict can be destructive and inhibit effective interprofessional health care team communication and outcomes.

Negative conflicts in teams can result from a variety of social behaviors. For example, some members of a team may have different viewpoints than others, biases or perceptions about various issues and be unwilling to change. Not surprisingly, individual personalities can lead to problematic differences in opinions, or worse, an unwillingness to share information and communi- cate openly with other team members. Also knowledge differences, not just related to health education but to what is shared among members, can lead

Reflection 9.6. Recall one of the groups/teams you are/have been a member of (family, team, school, professional) and reflect on how a member assumed one of the roles and communicated based on that. How did his or her role/behaviors impact the group’s/team’s work and your perception of the group/team?

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to problematic team conflict. Similarly, differences in members’ cultures and cocultures, as well as status differences (perceived and real) can lead to dis- agreements and obstacles to effective interprofessional team communication. It is important to also note that conflicts can be directed at people (a mem- ber or members), or at tasks (ideas, decisions, problem solving, etc.), or both. Team members need to identify the most effective communication approach to overcoming negative/unproductive conflict.

One of the ways to overcome conflict is to use effective interpersonal communication and try to both understand the other person’s views and, if possible, why he or she holds them. Although it may be helpful to try and persuade the person to consider a different approach to the disagreement, if that does not work, members can try to find a compromise that can result in a win–win–win for involved members, but also for the entire team. However, teams should be very careful to not allow a conflict, regardless of its origin, to dissolve into a personal attack on a member, or communication behaviors that can be perceived as emotionally aggressive and/or hostile. To minimize neg- ative/unproductive conflict and maximize diverse inputs/productive conflict, teams need to develop a supportive climate.

A supportive team climate is an environment in which members feel comfortable sharing information, voicing concerns and/or differing viewpoints. Tandy (1992) pointed out that the more supportive the team climate the more likely it will reduce stress and burnout for members and increase team productivity. Furthermore, a supportive climate is enhanced not just by the verbal messages that members communicate, but also through their nonverbal cues (proxemics, kinesics, volume, tone, etc.). Also, teams generally respond positively when members think that they share some common feelings for one another. Therefore, empathic messages and listening communicate a caring attitude to teammates. Not surprising, the more equality and openness to others’ ideas, concerns, and communica- tion team members can demonstrate, the more supportive the team climate will be perceived. Finally, in order to avoid a defensive/unproductive team climate, members need to try and avoid verbal and nonverbal behaviors that can be perceived by others as evaluating, controlling, uncaring, or superior. It is especially important to try to discourage members from taking rigid and egocentric approaches to information sharing, problem solving, and/or deci- sion making—all of which negatively impact both the team climate and the opportunity to encourage diverse input and exploration. Interprofessional health care teams by their very nature have a number of obstacles to over- come related to roles, norms, status, and organizational structure. However, by using effective team communication to encourage information sharing, diverse viewpoints, and a supportive climate, interprofessional health care teams can be extremely productive, successful, and beneficial in attaining both the team and organization’s goals as well as ensuring the most effective patient care possible.

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174 Health Communication for Health Care Professionals

R e f l e c t i o n s ( a m o n g t h e p o s s i b l e r e s p o n s e s )

9.1. Think about a nonhospital team/group you have been or are a member of. What would be the impact on the team’s goals if tomorrow someone with the same skills suddenly replaced one member? And then 2 days later, the original member returns, but now a different member is replaced? How would you expect these changes to impact the team’s process, production, communication, time management, and out- comes? Why?

Generally, most teams/groups have members who are consistent for the most part. Think of a professional sports team, for example, most of them perform much better and attain their goals the more they can keep the makeup of the team constant. Clearly, members may have to move in and out for injuries or unexpected life events, but the more frequent the change in personnel, the less likely the team will function at its ultimate capac- ity and attain both its and the organization’s goals—winning a champion- ship for a professional sports team. Some of the reasons why the evolving membership negatively impacts team performance is related not just to the specific skills, knowledge, and athleticism of the individuals (in or out), but also to the changes in nonverbal and verbal interpersonal and team com- munication among the teammates. This notion of constancy and its impact on team outcomes makes the amazing work of health care interprofessional teams—with the constant change in specific members coupled with fre- quent goal attainment—seem very impressive, but also important to be very aware of as team members.

9.2. Can you recall a team you were a member of—sports, academic, or professional— how did you work interdependently to accomplish the team’s goals? What made that team different from others that were not as successful?

Regardless of the team—sports, academic, or professional—in all likelihood you brought your individual skills, talents, and knowledge to your role and, when combined interpersonally with the other members of the team, the members’/team’s goals were attained. In order to be successful it is critical for a team to have the most effective combination of individuals, roles, and skills needed, but it is just as important to have those members not just function independently, but collaboratively. In order to do that most effectively, positive and productive team climate and communication that encourages participa- tion, diversity, and supportive behaviors are required.

9.3. How do you think the clarity of role distinctions in health care teams might enhance and/or diminish effective interprofessional communication? Why?

In health care, clinical roles are clearly delineated by academic degree, certifica- tion, licensure, and so forth. Whether a provider is an MD/DO, RN, APRN, PA,

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his or her role is very obvious to all members of the hospital or other health care organization. Therefore, health care teams are generally comprised based on cocultures—intraprofessional teams (physicians, or nurses, or PAs), as well as on interprofessional teams (MD/DO, RN, PA, APRN, resident, etc.). The clearly designated roles/professions of the various members alleviate any questions regarding clinical roles. However, the team roles and whether status, power, or diversity will lead to a supportive or defensive team climate must be constantly assessed, as well as the impact of the interchangeable nature of specific individ- uals on the culture of interprofessional health care teams.

9.4. Can you recall some norms, stated or understood, for a team you were a member of? How did these norms aid or detract from effective communication and/or goal attainment? Why?

Teams all have norms, some are clearly communicated: you should be here by 8:00 a.m. Or you are expected to be ready to present your patient when the team enters the room. However, others may not be communicated but are understood—if you are a member of a sports team you need to be dedicated and perform to your maximum potential. Similarly, in health care interprofes- sional teams, some of the norms could be related to who takes notes, or who gathers the patients’ lab values, vital signs, and so forth. Norms are critically important to the effective communication and functioning of interprofessional teams. Part of each team member’s responsibility is to learn the team’s norms and share them with new members in order to assure expected behaviors and maximum information sharing and time management.

9.5. Have you worked in a group/team in which one or more members had a higher status than you? If so, how did it impact your group/team communication? If not, what are your views of the issues listed previously in terms of status differences?

It is not uncommon, especially in families and professional groups/teams, for members to have different levels of status. For example, parents in a fam- ily group/team usually have a higher status than their children, and, based on birth order, siblings often have lower status if they are not the oldest, and so forth. On sports teams, coaches and/or captains often have per- ceived higher status than other members. In health care teams, doctors often have higher status, followed by nurses and midlevel providers. However, in order for teams to function most effectively, members need to feel that status differences should not impact tasks, information sharing, idea gen- eration, problem solving, and/or decision-making goals. Although status in health care is a long-standing reality, the current effort to increase diversity and interprofessional collaboration and participation seeks to minimize the impact of status on team communication and increase the value of diverse input and analyses in patient care.

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176 Health Communication for Health Care Professionals

9.6. Recall one of the groups/teams you are/have been a member of (family, team, school, professional) and reflect on how a member assumed one of the roles and com- municated based on that. How did his or her role/behaviors impact the group’s/team’s work and your perception of the group/team?

Many teams/groups have members who choose to take on a team role, for example, there may be a “blocker” in a group/team you have been a member of. This person perceives his or her role as constantly being the so-called “devil’s advocate” and stubbornly disagrees with most, if not all suggestions, ideas, and so forth; at times the blocker can appear to be creating conflict for no appar- ent reason—other than to be negative and an obstructionist. Clearly, members who assume roles that detract from effective team communication can make it very difficult to complete tasks, solve problems, make decisions, and attain goals. Consequently, teams must be very cognizant of how members are com- municating/behaving and work together to try and discourage members from assuming team roles that will be detrimental to effective communication and a supportive team climate.

S k i l l s E x e r c i s e

In a team that you are active in, family, school, work, health care, and so forth, ask as many individual members as possible what he or she thinks are the three most important norms for the team? You should be sure he or she understands the term, “norms.” In what way(s) are their responses similar to or different yours? Once you have tallied and analyzed the responses—share your findings with the team and discuss whether they feel the norms are helpful, or prob- lematic and what might be needed to make the norms contribute to a more supportive team climate.

Video Ace my homework – Write my paper – Online assignment help tutors – Discussion Exercise Analyze the video

■ Apollo 13 (1995)

Interactive Simulation Exercise Pagano, M. (2015 – Research Paper Writing Help Service). Communication case studies for health care professionals: An

applied approach (2nd ed.). New York, NY: Springer Publishing Company.

■ Chapter 9, “I’ve Got the License, So We’re Doing It My Way” (pp. 91–100)

Health Care Issues in the Media Health care as a team sport https://www.ted.com/talks/eric_dishman_health_care_should_be_a_team_ sport

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https://www.ted.com/talks/eric_dishman_health_care_should_be_a_team_sport
https://www.ted.com/talks/eric_dishman_health_care_should_be_a_team_sport
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H e a l t h C o m m u n i c a t i o n O u t c o m e s

Interprofessional health care team communication is critical to 21st-century patient care and successful health organization goal attainment. Regardless of the type of health care facility, developing effective intra- and interprofes- sional teams is vital to accomplishing tasks, solving problems, and assuring collaborative decision making. In order to provide the best potential outcomes, several factors involving intra- and interprofessional health care teams need to be carefully addressed and analyzed, including team norms, roles, status differences, and relationships. Similarly, the importance of diversity to inter- professional health care teams, not merely in clinical roles, but with regard to sex, age, education, culture, and so forth. It is vital that health care teams use diversity to expand thinking, analysis, task completion, problem solving, and decision making. At the same time, these teams need to recognize that with diversity, including status differences and role distinctions, comes the poten- tial for negative conflict. Consequently, interprofessional health care teams need to work to encourage positive conflict and maximize idea generation, input, and collaborative information sharing. In order to encourage this posi- tive use of diversity and minimize the risk of groupthink, or negative conflict— health care teams should strive to create supportive team climates.

■ R E F E R E N C E S

Benne, K., & Sheats, P. (1948). Functional roles of group members. Journal of Social Issues, 4, 41–49.

Tandy, C. (1992). Assessing the functions of supportive messages. Commu- nication Research, 19, 175–192.

■ B I B L I O G R A P H Y

Campbell, S. H., Pagano, M., O’Shea, E. R., Connery, C., & Caron, C. (2013). The development of the Health Communication Assessment Tool: Enhancing relationships, empowerment and power-sharing skills. Clinical Simulation in Nursing, 9, e543–e550. Retrieved from http://dx.doi.org/10.1016/ j.ecns.2013.04.016

Cragan, J., Kasch, C., & Wright, D. (2009). Communication in small groups: Theory, process, skills. In Managing group conflict (7th ed., pp. 243–275). Boston, MA: Wadsworth.

Engleberg, I., & Wynn, D. (2007). Working in groups. In Verbal and nonverbal com- munication in groups (4th ed., pp. 121–148). Boston, MA: Houghton Mifflin.

Hoover, J. (2005). Effective small group and team communication. In Team deci- sion making and problem solving: Types and procedures (2nd ed., pp. 88–106). Belmont, CA: Thomson-Wadsworth.

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http://dx.doi.org/10.1016/j.ecns.2013.04.016
http://dx.doi.org/10.1016/j.ecns.2013.04.016
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Mannix, E., & Neale, M. (2005). What makes a difference? The promise and reality of diverse teams in organizations. Psychological Science in the Public Interest, 6, 31–55.

Rothwell, J. (2015 – Research Paper Writing Help Service). In mixed company: Communicating in small groups and teams. In Roles in groups (9th ed., pp. 134–162). Boston, MA: Cengage.

Weiss, D., Tilin, F., & Morgan, M. (2013). The interprofessional health care team: Leadership and development. In Group development (pp. 19–38). Sudbury, MA: Jones & Bartlett.

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CAMPUS. All use subject to https://www.ebsco.com/terms-of-use

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CHAPITRE 9: TEAM COOPERATION

For the sake of this text, we will take the following definitions as working definitions:

■ Clinical simulation: Health care providers (students and/or professionals) role-playing scripted scenarios to enhance clinical care, health commu- nication, and reduce provider stress; may include a student/professional, or paid actors or can be done with a computerized mannequin

■ Communication climate: The atmosphere, environment, and/or conditions that impact small-group/team communication; can be positive, neutral, or negative

■ Norms: Rules or standards groups/teams use to communicate what behaviors are acceptable, expected, and/or unacceptable

■ Small-group/team communication: Three to 20 individuals working together interdependently to accomplish common goals; 13 is thought to be the ideal number for a small group/team

■ Social exchange theory: Explains group/team behavior in terms of positives
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