Chapter 7: Healthcare Communication Skills - Nursing

Chapter 7 Health-care professionals need to communicate clearly and effectively with each other. When they fail to do so, patient safety is at risk. In this case, the nurse practitioner failed to communicate a change in the patient's status, which resulted in a situation causing the patient's death...

Chapter 7 Health-care professionals need to communicate clearly and effectively with each other. When they fail to do so, patient safety is at risk. In this case, the nurse practitioner failed to communicate a change in the patient's status, which resulted in a situation causing the patient's death. Today's health-care system requires nurses to interact with more than physicians. Health-care providers include advanced practice nurses and physician assistants who work with physicians. Other disciplines involved in direct patient care include pharmacists, dietitians, social workers, physical and occupational therapists, speech-language pathologists, and ancillary unlicensed personnel. Effective communication among all members of the health-care team is essential in the provision of safe patient care. Based on the changes in health care, the report from the Institute of Medicine (IOM), and the move toward an interprofessional model of care delivery, this chapter focuses on communication skills needed to work with members of the interprofessional team and provide information in a multicultural environment. Communication People often assume that communication is simply giving information to another person with one person serving as a sender and another as a receiver (Wood, 2016). In fact, giving information is only a small part of communication. Communication models demonstrate that communication occurs on several levels and includes more than just giving information. Communication involves the spoken word as well as the nonverbal message, the emotional state of people involved, outside distractions, and the cultural background that affects their interpretation of the message. Superficial listening often results in misinterpretation of the message. An individual's attitude and personal experience may also influence what is heard and how the message is interpreted. Active listening is necessary if one is to grasp all the levels of meaning in a conversation. Assertiveness in Communication Nurses are integral members of the health-care team and often find themselves acting as "navigators" for patients as they guide them through the system. For this reason, nurses need to develop assertive communication skills. Assertive behaviors allow people to stand up for themselves and their rights without violating the rights of others. Assertiveness is different from aggressiveness. People use aggressive behaviors to force their wishes or ideas on others. Assertive communication, in contrast, requires an individual to firmly state a personal position using "I" statements. When working in an interprofessional environment, assertiveness assumes greater importance as nurses need to act as patient advocates to ensure that patients receive safe, effective, and appropriate care. Using assertive communication helps in expressing your ideas and position; however, it does not necessarily guarantee that you will get what you want. Interpersonal Communication Communication is an integral part of our daily lives. Most daily communication qualifies as impersonal, such as interactions with salespeople or service personnel. Interpersonal communication is a process that gives people the opportunity to reflect, construct personal knowledge, and develop a sense of collective knowledge about others. Individuals use this form of communication to establish relationships to promote their personal and professional growth. This type of communication remains key to working effectively with others. Interpersonal communication differs from general communication in that it includes several criteria. First, it is a selective process in that most general communication occurs on a superficial level. Interpersonal communication, in contrast, occurs on a more intimate level. It is a systemic process as it occurs within various systems and among the members within those systems (Wood, 2016). The work of the system influences how we communicate, where we communicate, and the meaning of the communication. Interpersonal communication is also unique in that the individuals engaged in the communication are unique. It is more than a linear interaction between someone sending a message and another individual receiving that message. Because each person holds a specific role that influences the form and process of the communication, they, in turn, impact the outcome. Finally, interpersonal communication is a dynamic and ongoing process. The communication changes based on the need and the situation. Transactional models of communication differ from earlier linear models in that the transactional models label all individuals as communicators and not specifically as "senders" or "receivers." They highlight the dynamic process of interpersonal communication and the many roles individuals assume in these interactions. These models also allow for the fact that communication among and between individuals occurs simultaneously as the participants may be sending, receiving, and interpreting messages at the same time (Wood, 2016). Transactional models acknowledge that noise, which interrupts communication, occurs in all interactions. Noise may assume many forms, such as background conversations within the workplace or even spam or instant messages in the electronic milieu. Transactional models also include the concept of time, as communication among and between individuals changes through time and acknowledges that communication occurs within systems. These systems influence what people communicate and how they relay and process information. Barriers to Communication Among Health-Care Providers and Health-Care Recipients Successful interactions among health-care providers and between those providers and their patients require effective communication. Breakdown in communication is attributed to 50% of preventable medical errors (Konsel, 2016). Challenges that impede this communication include low health literacy, cultural diversity, cultural humility of health-care providers, and a lack of interprofessional communication education of providers (Issacson, 2014; Schwartz et al., 2010). In addition, time constraints, patient symptoms, anxiety and embarrassment, and information overload can challenge both the patient's and provider's ability to comprehend the communication (Ali, 2017). Another hindrance to effective communication is implicit or unconscious bias on the part of a communicator (The Joint Commission \[TJC\], 2016). Low Health Literacy Low health literacy is defined as the degree to which an individual can obtain, process, and understand the basic information and services needed to make appropriate health decisions (Osborne, 2018). The IOM reports that approximately 90 million Americans lack the health literacy needed to meet their health-care needs (IOM, 2012). In the United States, the estimated cost of low health literacy is as high as \$238 billion (Center for Health Care Strategies, 2013; National Patient Safety Foundation, 2012). Individuals who lack the skills necessary to acquire and use health-care information are less likely to manage their chronic conditions or medication regimens effectively. For this reason, they utilize health-care facilities more frequently and have higher mortality rates. Cultural Diversity Nurses work in environments rich in cultural diversity. This diversity exists among both professionals and patients. Culture affects communication in how the content of a message is conveyed, emphasized, and understood. Diverse cultural beliefs, customs, and practices influence both nurse and patient perception of care, as well as the ability for a patient to understand a personal illness and access the needed care (Department of Health and Human Services \[HHS\], Office of Minority Health, 2013). Understanding the impact that cultural diversity can have will allow you to communicate in an effective, understandable, and respectful way. Cultural Competence and Humility Cultural competence and humility affect the way health-care providers interact with each other and with the populations they service. Cultural competence includes a set of similar behaviors, attitudes, and policies that, when joined together, enable individuals or groups to work effectively in cross-cultural situations (HHS, Office of Minority Health, 2013). To practice with cultural competence, health-care professionals need to recognize and relate to how culture is reflected in each other and in the individuals with whom they interface. Cultural humility takes the concept of cultural competency one step further. We live in a diverse and ethnically rich world, so how do you prepare yourself to care for patients of varying backgrounds during the course of your daily patient care assignment? How does one remain culturally competent when faced with the melting pot of socioeconomic, cultural, and ethnic beliefs that exist in our communities and at the bedside? Tervalon and Murray-Garcia (1998) suggest that cultural humility rather than cultural competence may be a better way to "skillfully and respectfully negotiate cultural, racial, and ethnic diversity in clinical practice" (p. 117). Competence is defined as being able to accomplish something in an efficient manner, whereas cultural humility is an approach that allows us to let go of our personal point of view so that we may consider another's beliefs without bias or stereotype (Issacson, 2014). This ability to accept and understand others creates space for inclusion. Seeing the similarities in cultures and traditions can break down social or systemic barriers that may have prevented the inclusion of groups. In other words, beginning a conversation with the patient to understand what is culturally important to them can remove barriers to effective communication and clinical care. A nurse greets a young Black man who presents at a very busy inner city emergency department (ED) triage desk. He appears disheveled and angry as he asks for a particular dose of a specific pain medication. The nurse's initial thought is the man is exhibiting drug-seeking behavior; the nurse surmises that the patient is only here for medication and after quick triage tells him to have a seat in the waiting room. During the man's waiting time, he returns to the triage desk and demands to know when he will be seen by a physician. The nurse further decides that this man may be a threat and calls security to come to the waiting room. When the charge nurse hears the commotion, she speaks to the waiting patient and learns that he is from out of town on business and has a history of sickle cell anemia. He had been trying to manage the oncoming crisis and came to the ED for pain medication to tide him over until he could get home. The patient is quickly taken back to be seen by the ED physician. When following up with the triage nurse, the charge nurse learned that the nurse dismissed this patient as a drug addict because he was a young Black male in his 20s, disheveled, and angry. This assessment was based on the nurse's understanding of the community demographics and past experience rather than assessing the patient, reviewing his chief complaint, and exploring his past medical history. Considerations when engaging a patient and colleagues in conversations concerning care should include (Tervalon & Murray-Garcia, 1998): Practice self-reflection to become more aware of your biases and cultural predisposition to remain open to others' points of view. Recognize, acknowledge, and respect others' cultural beliefs and practices. Acknowledge that many patients perceive that nurses and physicians have power over them. Ensure care and engagement with patients is patient focused to ensure that when we engage with a patient, we are in fact learning about one unique individual and that person's beliefs and practices, not a particular culture or ethnic group. Interprofessional Communication Education of Health-Care Providers Challenges exist when communicating with professionals in other disciplines. Some difficulties in interprofessional communication are related to the use of concepts and terminology, or jargon, common to one specific discipline but not well understood by members of other professions. This interferes with another professional's understanding of the meaning or value of the situation. Effective and safe health-care delivery requires nurses to be cognizant of these possible barriers to communication with patients and among members of the health-care team (Schwartz et al., 2010). When nurses and other members of the health-care team lack effective communication skills, patient safety is at risk. Implicit Bias Implicit bias refers to attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner (Staats et al., 2015). This bias is formed during a lifetime and contributes to our social behavior. People will make assumptions based on cultural beliefs and traditions as well as their values (Ali, 2017). Oftentimes, these biases are automatic during our interaction with other people and can influence our clinical decision making and even treatment (TJC, 2016). A person's ability to recognize these biases can improve communication with patients and colleagues alike. Electronic Forms of Communication Information Systems and E-Mail Electronic Health Records and Electronic Medical Records The use of computer technology and documenting in the electronic medical record (EMR) is the norm in today's nursing practice, hospital care institutions, and throughout health care. The Health Information Technology for Economic and Clinical Health (HITECH) Act mandated the use of the electronic health record (EHR) by the year 2015 (Centers for Medicare and Medicaid Services \[CMS\], 2013a). This organization developed Medicare and Medicaid incentive payment programs to help physicians and health-care institutions transition from traditional record-keeping to the EHR. According to the HHS, "EHR adoption has tripled since 2010, increasing to 44 percent in 2012 and computerized physician order entry has more than doubled (increased 168 percent) since 2008" (CMS, 2013c). In 2015, 84% of all hospitals had a basic form of EHR (Henry et al., 2016). The goal of computerized record-keeping is to provide safe, quality care to patients. The use of electronic patient records allows health-care providers to retrieve and distribute patient information precisely and quickly. Decisions regarding patient care can be made more efficiently with less waiting time. Errors are reduced, patient safety is increased, and quality is improved. Two examples of improved safety measures are the use of barcode scanning for medication administration and labeling of laboratory samples. Information systems in many organizations also provide opportunities to access current, high-quality clinical and research data to support evidence-based practice (Gartee & Beal, 2012). Although the terms EMR and EHR are used interchangeably, they differ in the types of information they contain. EMRs are the computerized clinical records produced in the health-care institution and health-care provider offices. They are considered legal documents regarding patient care within these settings. The EHR includes summaries of the EMR. EHR documents are shared among varying institutions or individuals such as insurance companies, the government, and the patients themselves (CMS, 2013b). EHRs focus on the total health of a patient extending beyond the data collected in the health-care provider's office. They provide a more inclusive view of a patient's care and are designed to share information with other health-care providers, such as laboratories and specialists, so they contain information from all the clinicians involved in the patient's care. The EMR contains the medical and treatment history of the patients within that specific health-care provider's practice. Some advantages of the EMR compared with paper charts include the ability of the health-care provider to: Track data through time. Identify which patients need preventive screenings or checkups. Monitor patients' status regarding health maintenance and prevention, such as blood pressure readings or vaccinations. Evaluate and improve the overall quality of care within the specific practice. A disadvantage of the EMR is that it does not easily move out of the specific provider practice or health-care institution. Recent changes in technology are making the EMR accessible to affiliated health-care providers so that a hospital physician may be able to view a patient's past medical history and recent outpatient visits or test results. These exchanges offer providers access to important patient information drawn from a variety of places where that patient received care, not just within that person's network. This is extremely helpful when caring for patients with chronic conditions or frequent utilization of EDs for basic care. This electronic access to information, however, is not widespread; oftentimes, the patient record needs to be printed or saved to a disc, then delivered by mail to specialists and other members of the care team. Because security safeguards and firewalls are in place, EHRs also assist in maintaining patient confidentiality when compared with traditional paper systems. Health-care providers and institutions have strict policies in place to enforce processes that protect patient information, which include the use of passwords to limit accessibility to the computerized record and procedures to ensure compliance with federal and state patient privacy and confidentiality standards. Although any breach in confidentiality is unacceptable, this is especially true when famous people, friends, and family are hospitalized. Attempting to access information about a patient not directly under your care in most instances is considered a breach of patient privacy and confidentiality and could result in the loss of your job. It is important to remember to never share your password and always log off when stepping away from the computer. Fortunately, many organizations time out a user's access when a computer has been idle for as little as 5 minutes. This helps to protect you and prevent security breaches. The Computer on Wheels The advent of the EMR created an unforeseen challenge for nurses. Reinecke (2015) estimates that nurses spend approximately 35% of their shift documenting. Moving to the EMR meant nurses needed to use computers to do their real-time charting; however, computers were located at the nurses' stations away from patients. This in itself created a potential risk to patient safety. Oftentimes, the number of computers available was limited, sometimes making it difficult for nurses to document in a timely manner. Health care's solution to this was the computer on wheels (COW) or workstation on wheels (WOW). This mobile unit freed the nurse from waiting for a computer in the nurses' station and allowed for real-time documentation with the patient. A challenge with this type of technology at the bedside is that nurses can get overly focused on documenting rather than the patient. Things to consider when using a WOW or COW include: Make sure that the WOW or COW is either plugged in or that the battery is fully charged. Position the WOW or COW in such a way that it is not between you and the patient to ensure eye contact and the genuine nature of your interaction is conveyed to the patient. Log off when leaving the COW or WOW to ensure the security, privacy, and confidentiality of your documentation, especially if the COW or WOW is parked in the hallway. E-Mail E-mail has become a communication standard. Organizations use e-mail to communicate both within (intranet) and outside (Internet) of their systems. The same communication principles that apply to traditional letter writing pertain to e-mail. Using e-mail competently and effectively requires good writing skills. Remember, when communicating by e-mail, you are not only making an impression but also leaving a written record (Shea, 2000). The rules for using e-mail in the workplace are somewhat different than for using e-mail among friends. Much of the humor and wit found in personal e-mail is not appropriate for the work setting. In addition, emoticons are cute but not necessarily appropriate in the work setting. Professional e-mail may remain informal. However, the message must be clear, concise, and courteous. Avoid common text abbreviations such as "LOL" or "OMG." Think about what you need to say before you write it. Then write it, read it, and reread it. Once you are satisfied that the message is appropriate, clear, and concise, send it. Many executives read personal e-mail sent to them, which means that it is often possible to contact them directly. Many systems make it easy to send e-mail to everyone at the health-care institution. For this reason, it is important to keep e-mail professional. Remember the "chain of command": Always go through the proper channels. The fact that you have the capability to send e-mail instantly to large groups of people does not necessarily make sending it a good idea. Be careful if you have access to an all-company mailing list. It is easy to unintentionally send e-mail throughout the system. Consider the following example: A respiratory therapist and a department administrator at a large health-care institution were engaged in a relationship. They started sending each other personal notes through the company e-mail system. One day, one of them accidentally sent one of these notes to all the employees at the health-care institution. Both employees were terminated. The moral of this story is simple: Do not send anything by e-mail that you would not want published on the front page of a national newspaper or broadcasted on your favorite radio station. Although voice tone cannot be "heard" in e-mail, the use of certain words and writing styles indicates emotion. A rude tone in an e-mail message may provoke extreme reactions. Follow the "rules of netiquette" (Shea, 2000) when communicating through e-mail. Some of these rules are listed in Box 7-2. Text Messaging Text messaging is slowly replacing the phone conversation. It is a pervasive, real-time way to connect with friends, acquaintances, and even coworkers while on the job. Shorthand abbreviations have replaced longer, more commonly used phrases, and although widely accepted as a preferred way of communicating, messages can be misinterpreted because of the absence of voiced emotion and body language. Secure text messaging has been adopted by many hospitals and health systems. It is an easy way to communicate between the care team and oftentimes allows for more timely care interventions for patients. It is important to learn your organization's policies on the use of secure text messaging to avoid a possible communication breakdown. For example, many organizations support the use of text messaging between teams but prohibit the use of texts as a doctor's order. This means that you might have a text conversation with a patient's physician, at which time the decision to administer a new medication or order a test is made. The physician should then go to the patient's EMR and place the order in real time Generally speaking, there are no laws about texting; however, many employers have policies and procedures that may limit personal cell phone use during work hours. Text messaging is device neutral, which means that texts can be sent to a personal or work-supplied cell phone. Text messages can stay on devices indefinitely, which may leave a patient's protected health information (PHI) unsecured and accessible to unauthorized users (Storck, 2017). In an attempt to protect patient privacy and confidentiality, secure text messaging is being used in some health-care settings. This secure Health Insurance Portability and Accountability Act (HIPAA)-compliant electronic communication technology allows nurses and other providers to exchange patient information in a timely manner without risk to patient privacy and confidentiality. Usually this is done using appropriate security and password protection. Texting of confidential or patient information should never be done on a private cell phone. Social media is a mainstay in today's society. People post everything from their last meal, to selfies, to pictures of their experiences. Many of these entries are impromptu and lack a filter. Nurses and other health-care professionals are obligated to protect patient privacy and confidentiality at all times. This applies to social media posts as readily as it does the spoken word. Knowing your state board requirements and national guidelines about patient privacy and media use will help you protect your patient's privacy and your license. The National Council of State Boards of Nursing (NCSBN, 2018) published guidelines on how to avoid disclosing confidential information (Appendix 3). The American Nurses Association (ANA, 2011) offers six tips to avoid breaches of privacy and confidentiality Reporting Patient Information In today's health-care system, delivery methods involve multiple encounters and patient hand-offs among numerous health-care practitioners who have various levels of education and occupational training. Patient information needs to be communicated effectively and efficiently to ensure that critical information is relayed to each professional responsible for care delivery (O'Daniel & Rosenstein, 2008). If health-care professionals fail to communicate effectively, patient safety is at risk for several reasons: (a) Critical information may not be given, (b) information may be misinterpreted, (c) verbal or telephone orders may not be clear, and (d) changes in status may be overlooked. Medical errors easily occur given any one of these situations. Hand-Off Communications The transmission of crucial information and the accountability for care of the patient from one health-care provider to another is a fundamental component of communication in health care. Meant to be a step taken to assure continuity of care, the complexity of the patient's condition or the frequency of transfers involves multiple providers communicating with other professionals in addition to nurses; this situation creates gaps in communication and increases patient safety risk. It is estimated that 80% of serious medical errors are attributed to ineffective or incomplete hand-off communication between members of the health-care team (TJC, 2013). Consider the implications for a teaching hospital where there are more than 4,000 hand-offs every day (TJC, 2017). Nurses traditionally give one another a "report" whenever they transition a patient to another caregiver or department. Hand-off reports include nurse-to-nurse report given at the change of shift, sometimes called bedside shift report, or during the transfer of a patient from one patient care area to another (e.g., the ED to a medical--surgical unit or to a postacute facility such as a skilled nursing home or acute rehabilitation hospital). One prominent health-care system views the hand-off report as a "handover conducted at the bedside to transfer the patient's trust to the oncoming RN" (UCLA Health, 2012). In the report, pertinent information related to events that occurred is given to the individuals responsible for providing continuity of care (Box 7-4). Although historically the report has been given face to face, there are newer ways to share information. Many health-care institutions use audiotape, computer printouts, or care summary tabs in the EMR as mechanisms for sharing information. These mechanisms allow the nurses and other providers from the previous shift to complete their tasks and those assuming care to make inquiries for clarification as necessary. TJC defines the hand-off as not only a transfer of care but an acceptance by the nurse or provider of responsibility for a patient's care. This real-time process is done by effectively communicating specific patient information from one nurse to another to ensure the continuity and safety of patient care (TJC, 2014). In 2009, TJC incorporated "managing hand-off communications" in its national patient safety goals (TJC, 2013). TJC maintains that the report should be organized, concise, and complete, with relevant details so that both the sender and receiver of the report know what is needed for safe patient care. Not every unit or department uses the same process for giving a hand-off report, so organizing your facts or questions assures that the right details are shared between caregivers. The hand-off report process is easily modified according to the pattern of nursing care delivery and the types of patients serviced. Some examples include the intensive care units and EDs where walking rounds are used as a means for giving the report. Another approach is the bedside shift report where the nurse caring for the patient and the oncoming nurse conduct their hand-off report at the bedside with the patient and family. In both examples, nurses gather objective data as one nurse ends a shift and another begins; this allows nurses to discuss and clarify current patient status and set goals for care for the next several hours. However, larger patient care units may find the "walking report" time-consuming and an inefficient use of resources. It is helpful to take notes or create a worksheet while listening to the report. Many institutions now provide a computerized action plan to assist with gathering accurate and concise information during the hand-off report. This worksheet helps organize the work for the day (Fig. 7.1). As specific tasks are mentioned, the nurse assuming responsibility makes a note of the activity in the appropriate time slot. Patient status, resuscitation status, medications, diagnostic tests, and treatments should be documented. Changes from the prior day or shift should be noted, and any priority interventions and new orders should also be reviewed at this time. During the day, the worksheet acts as a reminder of the tasks that have been completed and of those that still need to be done. Many institutions are now using electronic tablets or WOWs to allow nurses and other health-care providers to collect, organize, record, and track activities Reporting skills improve with practice. When presenting information in a hand-off report, begin by identifying the patient, room number, age, gender, and health-care provider. Also include the admitting as well as current diagnoses. Address the expected treatment plan and the patient's response to any treatments or medications, especially those that may have occurred on your shift or the shift prior. For example, if the patient has had multiple antibiotics and a reaction occurred, or a recent change in pain medication which has affected their sensorium, this information is important and must be relayed to the next nurse. Avoid making value judgments and offering personal opinions about the patient. Communicating With the Health-Care Provider The function of professional nurses in relation to their patients' health-care providers is to communicate changes in the patient's condition, share other pertinent information, discuss modifications of the treatment plan, clarify orders, and generally speak out to advocate for their needs. This can be stressful for a new graduate who still has some role insecurity. Having the right information in front of you and using good communication skills are helpful when discussing patient needs, especially in critical situations. Before calling a health-care provider, make sure that all the information needed is available. The provider may want more clarification about the situation. For example, if calling to report a drop in a patient's blood pressure, be sure to have the list of the patient's medications, the last time the patient received the medications, laboratory results, vital signs, and blood pressure trends. Also be prepared to provide a general assessment of the patient's present status. Of note, there are times when a nurse calls or pages a physician or health-care provider and the health-care provider does not return the call. This call should be documented in the patient's record. If the provider does not return the call in a reasonable amount of time, or patient safety is in jeopardy, the nurse should follow the chain of command to make sure patient safety is maintained. Involving your immediate supervisor in these situations can allay any concerns you have about escalating communication for your patient's health needs. ISBARR Miscommunication contributes to approximately 80% of preventable adverse events, including death, during hospitalization. It is estimated that a typical teaching hospital has more than 4,000 patient hand-offs or handover reports per day (TJC, 2017). Loosely translated, that is 4,000 opportunities for patient harm because of lapses in communication. Given this statistic, both TJC and the Institute for Health Care Improvement (IHI) have mandated that health-care institutions employ a standardized reporting or hand-off system and promote the use of the SBAR technique (Haig et al., 2006; IHI, 2006; Robert Wood Johnson Foundation \[RWJF\], 2013; TJC, 2013, 2017). Although originally established by the U.S. Navy as SBAR (Situation, Background, Assessment, and Recommendation) to accurately communicate critical information, the technique was adapted by Kaiser-Permanente as an "escalation tool" to be implemented when a rapid change in patient status occurs or is imminent. This communication technique has recently been updated to ISBARR or ISBAR. ISBARR is an acronym for Introduction, Situation, Background, Assessment, Recommendation, and Readback (Enlow et al., 2010; Haig et al., 2006). Another communication tool used to convey timely, accurate information to oncoming nurses is called I PASS the BATON (World Health Organization \[WHO\], 2011). This mnemonic, short for Introduction, Patient, Assessment, Situation, Safety concerns, Background, Actions, Timing, Ownership, and Next (actions), outlines the steps taken to ensure timely concise and accurate communication to the oncoming nurse or provider. Whether using SBAR, ISBARR, or I PASS the BATON, these techniques provide a framework for communicating critical patient information in a systemized and organized fashion. These methods focus on the immediate situation so that decisions regarding patient care may be made quickly and safely. The format helps to standardize a communication system to effectively transmit needed information to provide safe and effective patient care. Table 7-2 and Table 7-3 illustrate the ISBARR and I PASS the BATON communication tools, respectively. The implementation of ISBARR and I PASS the BATON as communication techniques has demonstrated success in reducing adverse events and improving patient safety. It also allows nurses, health-care providers, and members of the interprofessional team to communicate in a collegial and professional manner Health-Care Provider Orders and Order Sets Professional nurses are responsible for accepting and implementing health-care provider orders. It is important to remember that nurses may only receive orders from physicians, dentists, podiatrists, and APPs such as nurse practitioners who are licensed and credentialed in the state in which they are working. Orders written by medical students need to be countersigned by a physician before implementation. The four main types of orders are written, telephone, faxed, and electronic. Some health-care institutions are looking into the possibility of receiving health-care provider orders through e-mail and secure texting. These orders include the provider's name, date, and time and provide an electronic record of the order. Written orders are dated and placed on the appropriate institutional form. The health-care provider gives telephone orders directly to the nurse by telephone. Faxed orders come directly from the health-care provider office and need to be initialed by the provider. Telephone orders, e-mail orders, and faxed orders need to be signed when the health-care provider comes to the nursing unit. The electronic orders give providers the ability to access the patient record from remote locations, which is slowly eliminating the need for telephone and faxed orders in many institutions. For this reason, health-care institutions may no longer accept telephone, e-mail, or fax orders as the health-care providers because they have direct access to the EMR from remote locations. It is important to verify the institution's policy on telephone, e-mail, and fax orders. The telephone order needs to be written on the appropriate institutional form, with the time and date noted and the form signed by the nurse. When receiving a telephone order, repeat it back to the provider for confirmation. If the health-care provider is speaking too rapidly, ask the individual to speak more slowly, then repeat the information for confirmation. If a faxed document is unclear, call the health-care provider for clarification. Most institutions require the health-care provider to cosign the order within 24 hours. Teams Teams and teamwork are everyday terms in today's organizations. Teams bring together the variety of skills, perspectives, and talents that create an effective work environment. Nursing is a "team sport." In other words, nurses bring a specific set of skills and talents and need to work together with other professionals to achieve a common goal. The goal in this case is safe, high-quality patient-centered care. Health-care providers understand that safe, quality patient care thrives in an environment that promotes interprofessional teamwork and collaboration. Not all teams are interprofessional teams, however, and it is important to understand that a team does not necessarily infer collaboration. In 2004, the IOM revealed that issues surrounding nursing competency contributed in part to ensuring patient safety. TJC (2017) estimates that 68.3% of adverse medical events resulting in patient harm are caused by teamwork failures and, in fact, may have been preventable. The Organization for Associate Degree Nursing (OADN) addressed these concerns and looked at collaboration and teamwork as a way to decrease medical errors and promote safe, high-quality care. OADN (2021) defined teamwork as the ability to perform "effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care." Kalisch and Lee (2011) conducted a study that looked at staffing, teamwork, and collaboration. The study supported the fact that teamwork contributes to safe quality care; however, health-care institutions need to provide adequate staffing to ensure collaboration and teamwork. Health-care institutions that choose to apply for American Nurses Credentialing Center (ANCC) Magnet™ designation must demonstrate how their staffing model promotes teamwork and interprofessional collaboration. Learning to Be a Team Player When asking for assistance, nothing is more frustrating to hear than, "Oh, he's not my patient" or "I have my own mess to deal with; I can't help you." A team player states, "I have not seen that patient yet today, but let me help get that information for you," or "How can I be of assistance?" Every team member brings value to the team through personal strengths and specific skill sets. To develop a strong team, members must treat each other with dignity and respect. They also must understand the role and scope of practice of each discipline. It is important for each member to identify their personal strengths, limitations, and competencies in order to function as a contributing member of the team. Being a team member does not automatically make you a team player. Team players consistently treat other members with respect, courtesy, and consideration. They demonstrate commitment, understand the team's goals, and support other team members appropriately. They care about the work and purpose of the team and they contribute to its success. Team players with commitment look beyond their own workload and provide support and assistance when and where needed (Nelson & Economy, 2010). The goal in the health-care setting is safe, high-quality patient care. Building a Working Team Building a strong team takes time and talent. Assuming that all the team members possess the skill sets that are needed, how do you create an effective, efficient team? Brounstein (2002) identified 10 qualities of an effective team player (Box 7-5). These qualities provide the foundation for a strong professional team. To build an effective team, first identify the team players and focus on the strengths and weaknesses of each. Teams are usually composed of key stakeholders who have a keen interest in the challenge or opportunity at hand. While building on the strengths, devise a plan to assist team members in addressing their weaknesses. Second, make sure that all members understand the team goal, know their role on the team, and are committed to achieving the desired outcome. In health care, the primary goal is safe, high-quality patient care. Third, act as a role model and exhibit the expected behaviors. Fourth, reward the team for accomplishments and achievements, discuss setbacks, and together create an improvement plan Interprofessional Collaboration and the Interprofessional Team Although building an interprofessional team seems practical, it requires a commitment and collaboration among members of all the disciplines (O'Daniel & Rosenstein, 2008). The IOM (2010), the National League for Nursing (NLN, 2015), the American Association of Colleges of Nursing (AACN, 2011), and the American Organization of Nurse Executives (AONE, 2012) issued statements supporting collaboration among all members of the health-care team with the purpose of providing safe, effective care and achieving positive patient outcomes. Research demonstrates that the quality of patient care is improved when team members collaborate (Keller et al., 2013). Integrated teams composed of health-care professionals who understand each other's unique roles and functions result in better clinical outcomes and greater patient satisfaction (WHO, 2011). As simple as this concept seems, it takes an integrated and dedicated approach to form a collaborative interprofessional team. Interprofessional Collaboration The WHO (2010) defines interprofessional collaboration as occurring when "multiple health workers from different professional backgrounds work together with patients, families, caregivers, and communities to deliver the highest quality care (WHO, 2010, p. 7)." Collaboration differs from cooperation. Cooperation means working with someone in the sense of enabling: making them more able to do something (typically by providing information or resources they wouldn't otherwise have). Collaborating (from Latin laborare, "to work") requires working alongside someone to achieve something (Martin et al., 2010). The fundamental difference between collaboration and cooperation is the level of formality in the relationships between agencies and stakeholders. For many years, members of other health-care disciplines cooperated with each other. For example, nurses and physicians cooperated with each other in patient care delivery. However, inequalities existed between the disciplines regarding shared expertise and power (RWJF, 2013). Collaboration can and should happen every time people come together to solve a problem or establish goals. As a nurse, you will experience collaboration multiple times every work day. Knowing and recognizing the characteristics of collaboration will ready you as a professional nurse. A true collaborative effort comprises the following key components: sharing, partnership, interdependency, and power (O'Brien, 2013). Collaboration assumes that members share responsibility, values, and resources. To engage in partnership, members need to be honest and open with each other, demonstrate mutual trust and respect, and value each other's contributions and perspectives. Members of an interprofessional team are dependent on each other and work with each other to achieve a common goal. Finally, power is shared among the members. The health professionals recognize their own individual scope of practice and skill set while demonstrating an appreciation for the other members' expertise, capabilities, and contributions. They also share in the accountability for the delivery of patient care. This shared effort among health-care professionals helps to coordinate care and promote patient safety and quality of care. Interprofessional Communication Breakdowns in verbal and written communication among health-care providers present a major concern in the health-care delivery system. TJC (www.tjc.org) attributes a high percentage of sentinel events to poor communication among health-care providers (2013, 2017). Communication is considered to be a core competency to promote interprofessional collaborative practice. Using a common language among the professions assists in understanding and overcoming barriers to interprofessional communication. The ISBARR and I PASS the BATON methods were discussed earlier in the chapter. A team-related method of communication, Team STEPPS, developed by the Department of Defense (DoD) and the Agency for Healthcare Research and Quality (AHRQ), is another method. The purpose of this teamwork system is to improve collaboration and communication related to patient safety (AHRQ, 2013). This method includes four skills: leadership, situation monitoring, mutual support, and communication. The program goals focus on (a) creating highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes for patients; (b) increasing team awareness and clarifying team roles and responsibilities; (c) resolving conflicts and improving information sharing; and (d) eliminating barriers to quality and safety. The program is composed of training modules available to health-care institutions. With the goal of collaboration among health-care professionals to promote continuity of care and facilitate communication, many health-care institutions have created a position known as the "nurse navigator." The function of the navigator is to coordinate patient care by guiding patients through the diagnostic process, educating and supporting patients and families, integrating care with other members of the interprofessional team, and assisting them in making informed decisions (Brown et al., 2012). Nurses are an integral part of the interprofessional health-care team. Nurses usually have the most contact with the patients and their families. They often find themselves in an advantageous position to observe patient response to treatments and report these back to the interprofessional team. For example: Mr. Richards, a 68-year-old man, was in a motor vehicle accident and sustained a traumatic brain injury. He had right-sided weakness and dysphagia. The health-care provider requested evaluations and treatment plans from speech pathology, physical therapy, and social services. The speech pathologist conducted a swallow study and determined that Mr. Richards should receive pureed foods for the next 2 days. The RN assigned a licensed practical nurse (LPN) to feed Mr. Richards a pureed lunch. The LPN reported that although Mr. Richards had done well the previous day, he had difficulty swallowing even pureed foods today. The RN immediately notified the speech pathologist, and a new treatment plan was developed. Building an Interprofessional Team Effective interprofessional teams include several characteristics and focus on the needs of the patient, not the individual contributions of the team members. Each member understands the characteristics of collaboration and demonstrates a willingness to share, recognize the others' expertise, and participate in open communication. Members of a team are expected to share information through verbal and written communication regularly to ensure safe, timely care for patients. This may be done in different settings, such as daily bedside rounds or more formal team conferences for long-term care planning. The characteristics of an effective interprofessional health-care team are listed in Box 7-6. Interprofessional teams communicate by engaging in conferences and multidisciplinary patient rounds. These groups begin with the presenter, usually the primary nurse, stating the patient's name, age, and primary diagnosis. Each team member then explains the goal of their discipline, the interventions, and the intended outcomes. The effectiveness of treatment, development of new interventions, and setting of new goals are discussed. All members contribute and participate, demonstrating mutual respect and valuing the expertise of the others including nursing assistive personnel (NAP) as appropriate. A method to oversee the implementation of the plan is devised in order to assess outcomes and make adjustments as needed. The nurse (or nurse navigator) is often the individual who assumes the responsibility for this oversight. The key to a successful interprofessional conference is presenting information in a clear, concise manner and ensuring input from all disciplines and levels of care providers Conclusion The responsibility for delivering and coordinating patient care is an important part of the role of the professional nurse. To accomplish this, nurses need good communication skills. Being assertive without being aggressive and interacting with others in a professional manner enhance the relationships that nurses develop with colleagues, health-care providers, and other members of the interprofessional team. A major focus of the national safety goals is improved communication among health-care professionals and the development of interprofessional health-care teams. In an effort to improve patient safety, health-care institutions have implemented communication protocols referred to as the SBAR method or Team STEPPS. SBAR sets a specific procedure that reminds nurses how to relay information quickly and effectively to the patient's health-care provider, which ultimately leads to improved patient outcomes. Team STEPPS, developed by the DoD, assists health-care institutions in promoting patient safety through communication and coordination of patient care. Collaboration and teamwork encourage interprofessional collegial relationships that promote safe quality patient care. Key nursing organizations, the IOM, QSEN, and ANCC Magnet™ criteria address the need for collaboration and teamwork. Nurses act as key players in ensuring interprofessional communication and collaboration in patient care delivery. Finally, health-care institutions need to be committed to creating an environment that promotes communication and team collaboration. This needs to come from the top down and the bottom up to create an organizational culture that promotes patient safety. Nurses are in a unique position to act as change agents within their organizations by practicing safe, effective patient care; promoting collegial communications; and committing themselves to ensuring effective interprofessional collaboration