Teamwork and Collaboration PDF

1 Teamwork and Collaboration. 2 Objectives Describe the TeamSTEPPS framework. Identify barriers to effective teamwork Define teamwork and collaboration Describe the roles and functions of the nurse professional with other care professionals on the healt...

1 Teamwork and Collaboration. 2 Objectives Describe the TeamSTEPPS framework. Identify barriers to effective teamwork Define teamwork and collaboration Describe the roles and functions of the nurse professional with other care professionals on the healthcare team Explain how individual behavior and team dynamics in health care can make care safer or less safe Define a culture of safety and discuss the features of a strong safety culture Differentiate between each of the TeamSTEPPS basic tools and strategies Describe situational monitoring, situational awareness, and shared mental model Describe mutual support and strategies to foster mutual support (task assistance, feedback) Employ constructive methods of communicating and resolving conflict as part of a team  3 Paper Chain Exercise #1 Divide groups into teams of 3-4 students The goal is to create the longest paper chain with the materials provided. Everyone will be given 2 minutes to create their chain.  4 Debrief for 4 minutes  5 TeamSTEPPS Team Strategies & Tools to Enhance Performance & Patient Safety: https://www.ahrq.gov/teamstepps/index.html Based on more than 30 years of research and evidence Team training programs have been shown to improve attitudes, increase knowledge, and improve behavioral skills Salas, et al. (2008) meta-analysis provided evidence that team training had a moderate, positive effect on team outcomes (ρ =.38)  6 Intentional Tools and Strategies of TeamSTEPPS Teamwork and Collaboration QSEN Definition: function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care Also known as collaborative health care  8 Interprofessional Team Roles and Functions Scope of practice may overlap with another profession Work collaboratively to provide holistic care Nurse is often the manager of care Must understand roles and functions of other team members in order to make appropriate consults and referrals Intraprofessional: within the profession Nurse aids Interprofessional: outside the profession  9 Interprofessional Team: Match the team member with the role 1.Spiritual Support A. Client is SOB and needs a nebulizer treatment 2.Speech Pathologist B. Client is needing medical equipment in the home after discharge 3.Social Worker C. Client requests communion prior to surgery 4.Respiratory therapist D. Client is needing an x-ray after a fall 5.Radiology technologist E. Client has a temp of 102 and is achy 6.Provider F. Post op hip replacement needs assistance to ambulate and regain strength 7.Physical therapist G. Client having difficulty using an eating utensil post CVA 8.Occupational therapist H. Provider needs to see the lab report immediately 9.Laboratory technician I. Client with low albumin and recent weight loss 10.Registered Dietician J. Client is having difficulty swallowing a regular diet 11.Pharmacist K. Client is concerned about the side effects of Coumadin Why is teamwork important? One person cannot provide all the expertise needed to care for patients. Health care teams can help or hinder safety 80 percent of serious adverse events are related to miscommunication. When wrong-site surgeries occur, there is usually somebody who could have prevented it — but didn’t speak up. As an individual, you must speak up! 26, 2016. Culture of Safety Characteristics Psychological Safety: People treat each other with respect. Active Leadership: Everyone is encouraged to speak up about safety concerns. Fairness: People are not unfairly blamed. Transparency: It is safe to talk about mistakes and errors. People learn from these events and treat them as opportunities to improve. 12 What makes someone a leader? Leaders are not identified by position or rank; they exist at all levels and in all groups. Strong leaders in health care, who promote a culture of safety, do the following: Make yourself approachable through psychological safety and trust Establish shared goals Invite everyone into the conversation Team Horrors It's a Tuesday morning, and you and your colleagues are waiting in the OR for the arrival of the surgeon. She is running 30 minutes late. As you prepare for the surgery, you chat with your colleagues about their weekend. The surgeon enters the room and all talking stops. She smiles briefly and walks toward the patient. She turns to the team and says, "I am late, and we have a patient waiting here, people. Let's get moving and get this done." The team is mostly silent during the procedure. The surgeon has loud music playing and indicates she would rather listen to the music than talk with the team. During the surgery, the surgeon removes both ovaries. At the close of the surgery, the surgeon says a brief thank you to the team and leaves the OR. The patient wakes up and realizes that both of her ovaries were removed and the consent stated only the right ovary was to be removed. The patient is now unable to have children. Is this a culture of safety? What characteristics are missing? What behaviors are missing? Would you want to work in this environment? Would you want to be a patient in this environment?  Team Harmony It’s a Tuesday morning, and you and your colleagues are waiting in the OR for the arrival of the surgeon. She is running 30 minutes late. As you prepare for the surgery, you chat with your colleagues about their weekends. The surgeon arrives and says, "Hi, I’m Kelly Birru. I apologize for being late; one of my other cases ran long. Before we get started, let's go around the room and introduce ourselves. I want to make sure we’re all on the same page." Everyone on the team does brief introductions. The surgeon encourages everyone to participate in the process and says, "If you see something troubling or have a question, please speak up." The team conducts a time-out to confirm the correct patient and surgical site and discusses a few of the issues that may come up during the case. At the end of surgery, the surgeon thanks every team member by name and asks for input on what went well and what could be improved.  16 TeamSTEPPS Basic Tools and Strategies Situational Monitoring (includes awareness and shared mental model) Status of the patient, Team members, Environment, Progress towards goal Leading Teams Briefs, Huddles, Debriefs Communication ISBARR, Call-out, Check-Back, Handoff Mutual Support Task assistance, Feedback, Assertive statement, Two Challenge Rule, CUUS, DESC Script  17 Situation Monitoring, Awareness, Mental Model Give an example of when you have used this tool  18 Situation Monitoring (an individual skill) Process of actively scanning and assessing elements of the situation to gain information or maintain an accurate understanding of the situation in which the team functions. Skill that can be taught, developed, and improved Enables team members to identify potential issues or minor deviations early enough to correct and handle them before they become a problem or pose harm to the patient.  19 Situation Awareness (an individual outcome) The state of knowing the current conditions affecting one’s work. Includes knowing… Status of the patient Team member status Environmental conditions Progress toward the goal  20 Conditions That Undermine Situational Awareness Failure to— Share information with the team Request information from others Direct information to specific team members Include patient or family in communication Utilize resources fully (e.g., status board, automation) Maintain documentation Know and understand where to focus attention Know and understand the plan Inform team members the plan has changed  21 Shared Mental Model (a team outcome) Result of each team member maintaining his or her situation awareness and sharing relevant facts with the entire team Doing so, helps ensure that everyone is on the “same team”  22 Shared Mental Model?  23 Leading Teams: Briefs A team briefing is an effective strategy for sharing the plan Usually occur before a procedure Briefs should help: Form the team Designate team roles and responsibilities Establish climate and goals Establish plan Workload and available resources Example: Time-Out prior to surgery  24 Leading Teams: Huddle (ad hoc meeting during an event) Tool for communicating adjustments to a plan of care already in place. When a plan changes as result of changes in the patient or team, or aspects of the plan are not working, a huddle should be convened Helps to establish or reestablish situational awareness  25 Leading Teams: Debriefs At the completion of an event Designed to improve outcomes Teams decompress What went well, what did we do good? What could have been done better? What lesson did we learn?  26 Communication: Check back or Repeat Back Check back/Repeat back is a closed-loop communication strategy used to verify and validate information exchanged. Sender concisely states information to the receiver Receiver repeats back what he or she heard Sender acknowledges information is correct or corrects it Process continues until shared understanding is confirmed Example: One member of the team calls out, “BP is falling, 80/48 down from 90/60.” Another team member verifies and validates receipt of the information by saying “Got it; BP is falling and at 80/48, down from 90/60.” The original sender of the information completes the loop by saying, “Correct.”  27 Communication: Call-Out A strategy used to communicate important or critical information Critical information is called out during the situation It informs all team members simultaneously during emergency situations It helps team members anticipate next steps Works best to direct information to specific individual on the team so that a response can be given Example: During code blue, the nurse checks for a pulse and calls out “no pulse” and looks at the code leader. The code leader responds with “continue compressions.” Communication: SBARR Technique A framework for team members to effectively communicate about a patient’s condition to one another Communicate the following information: Situation―What is going on with the patient? Background―What is the clinical background or context? Assessment―What do I think the problem is? Recommendation―What would I recommend? Read back orders to confirm what is written down 29  y, an 30 im pri Communication: Handoffs nt of El se Standardized strategy designed to enhance information vi er In exchange at critical time such as transitions in care. c. Includes opportunity to ask and respond to questions Maintains continuity of care despite changing caregivers In the emergency department, one service takes over for another, such as gynecology taking over for general surgery for a patient with pelvic pain. Within the hospital, a patient is moved from one unit to another, such as from the postoperative recovery room to the intensive care unit. After being hospitalized, a patient is discharged home or to a long-term care facility. In the outpatient setting, a primary care office transfers the patient to a specialty care practice or rehab facility. What percent of adverse events are due to faulty transitions (handoffs)? 80 percent of serious adverse events can be linked to miscommunication between caregivers when patients are transferred or handed over Common challenges: Adverse drug events Lost test results Incomplete referrals of Graduate Medical Education. 2012;4(1):48. Accessed April 26, 2016.  32 Mutual Support (back up behavior) Essence of teamwork Provides a safety net to help prevent errors, increase effectiveness, and minimize strain caused by work overload Mutual support involves: Task Assistance Providing and receiving feedback Assertive Statements Two Challenge Rule CUUS DESC Script  33 Mutual Support: Task Assistance Team members foster a climate in which it is expected that assistance will be actively sought and offered as a method for reducing the occurrence of error. Communicate clear and specific availability of time and skills Use common courtesy when asking for help Close the loop on task communication-ensure it was completed correctly Account for experience level  34 Mutual Support: Feedback Feedback is information provided for the purpose of improving team performance Formal Retrospective and typically scheduled in advance Has an evaluative quality Examples: Collaborative discussions, case conferences, individual performance reviews Informal Typically in real time Provided on an ongoing basis Focuses on knowledge and practical skills development Examples: Huddles, debriefs  35 Mutual Support: Two Challenge Rule Empowers all team members to "stop the line" if they sense or discover an essential safety breach. Team member being challenged must acknowledge that concern has been heard. This is an action never to be taken lightly, but it requires immediate cessation of the process and resolution of the safety issue. If the safety issue still hasn't been addressed: Take a stronger course of action  36 Example of Two Challenge Rule It is late at night during a particularly hectic shift. A distressed young female having an allergic reaction arrives in the ED. She has developed a rash and is beginning to wheeze. Dr. Andrew, who is new to the ED, orders Benadryl 125 mg IV. Clara, an experienced pharmacy technician, questions the drug dosage. Dr. Andrew repeats his order for Benadryl 125 mg IV. Clara pursues her challenge a second time, stating, "Dr. Andrew, that dose seems high. I've never dispensed more than 50 mg IV at a time before." "Yes, you're right. I was confusing the dose with that for Solu-Medrol," states Dr. Andrew. Dr. Andrew changes his order, she repeats the correct order back to him, and the correct dose of Benadryl is administered. Mutual Support: Critical Language (CUUS) Assigns designated words or phrases to indicate escalating concern. Every team member needs a shared understanding of the language and knows to stop and pay attention I’m concerned...” “I’m uncomfortable...” “I feel it’s unsafe...” “I’m scared”  38 Critical Language Example (CUUS) “A prominent orthopedic surgeon is preparing to perform knee surgery. He is distracted, and a nurse in the room notices the surgeon’s scalpel is hovering over the incorrect knee. She wants to say something but is nervous about challenging his authority. “Excuse me, Doctor,” she says, “but I am concerned about which knee you are going to operate on.” The entire surgical team knows to stop immediately. As soon as they do, the physician realizes his error, and moves to the correct knee. He later thanks the nurse for using critical language.  39 Mutual Support: Advocacy and Assertion Advocate for the patient Invoked when team members’ viewpoints don’t coincide with that of a decision maker Assert a corrective action in a firm and respectful manner Respectful and supportive of authority Clearly asserts concerns and suggestions Is nonthreatening and ensures that critical information is addressed Five-Step Process: 1.Open the discussion 2.State the concern 3.State the problem—real or perceived 4.Offer a solution 5.Obtain an agreement  40 Example of Assertive Statement The nurse and healthcare provider are in the endoscopy suite, and a patient is undergoing a colonoscopy. The endoscopy nurse thinks she sees a possible lesion that may have been missed. Open the discussion: “Dr. Myers…” State the concern: “I thought I saw something abnormal looking in the cecum just as you started to withdraw the scope.” State the problem—real or perceived: “I can’t be certain, but the mucosa looked abnormal.” Offer a solution: “Since you’re so close, it would be easy to check the area.” Obtain an agreement: “Would you advance the scope back into the cecum and I’ll point out the area I thought might be abnormal?”  41 TeamSTEPP Video Analysis https://www.youtube.com/watch?v=lQM86b1fJqs https://www.youtube.com/watch?v=3uqcCZPgt7U Debrief this situation: What went well? What could be done better? What lessons did we learn that we will do differently next time?  42 Paper Chain Exercise #2 Divide groups into teams The goal is to create the longest paper chain with the materials provided. Take 5 minutes to identify the TeamSTEPPS tools and strategies you will be using during the paper chain exercise. Everyone will be given 2 minutes to create their chain. Your team must use at least 6 TeamSTEPPS tools and strategies during the exercise.  43 Team Concepts Culture of Safety: Were all members on our team encouraged to speak up? Did you treat each other with respect? Did members unfairly blame? Did you feel safe talking about an error? Team Structure: Did you have clearly defined roles? Was anyone wondering what to do because a clearly defined role was lacking? Communication: What information was communicated during the task? How did it help or hinder the team’s ability to perform the task? Did you use any structured communication techniques? Leadership: Did someone assume a leadership role and help the team plan? If no leader, how would this have helped? Situation Monitoring: Given the information shared at the start of the exercise, what were you monitoring throughout the task? Mutual Support: Did you offer to help your team members, rather than waiting for another member to complete the task?  44 Debrief  45 Mutual Support: Conflict in Teams  46 Incivility Defined as “rude, intimidating, dismissive action or verbal exchanges” which causes physiological and psychological problems for all involved. Behavior that interferes with effective communication among healthcare providers and negatively impacts performance and outcomes; behavior not supportive of a culture of safety Lateral Violence: incivility that goes from peer to peer (horizontal) Vertical Violence: incivility between a supervisor and a subordinate, or vice versa  47 Relationship Between Incivility and Bullying Incivility Behaviors: Someone embarrassing you in front of others; rudeness; gossiping Someone rolling their eyes at you Inappropriate tone used when speaking to you Someone avoiding taking a handoff report from you Sarcastic remarks made to or about you Someone raising their voice when speaking to you Not involving you in a client care decision Being told that you were incompetent Someone refusing to help you Bullying: recurring behavior involving unwelcome actions intended to harm, humiliate, or distress another. Incivility becomes bullying through repetition or harmful actions.  48 Negative effects of Incivility Medical errors Poor patient satisfaction Preventable adverse outcomes Increase in cost of care Decreased retention of health care workers  49 Strategies to Promote Collaboration ZERO Tolerance Policy: Ensures that code of conduct policies are highly visible, readily accessible, and applied consistently and fairly across all members of the workplace team. Conflict Management: Method to settle disagreements peacefully and respectfully, through compromise, and accommodation to each other’s needs, sharing goals, and avoiding competition with the other party. Cognitive Rehearsal: Intellectual therapeutic technique where one envisions or visualizes an overwhelming, or an anxiety-producing situation  50 Conflict: Neither Good or Bad How do you perceive conflict? It is a disagreement between individuals or groups who perceive a threat to their needs, interests, or concerns Functional or Dysfunctional; even Essential  51 Positive effects of conflict Stronger working relationships Improved staff retention Increased creativity, seeking better ways Greater patient safety Better workplace environment  52 Conflict Management A method to settle disagreements peacefully and respectfully, through compromise, and accommodation to each other’s needs, sharing goals, and avoiding competition with the other party.  53 You are starting out your day shift by obtaining report from the night shift nurse. As you walk in the room, you find it a mess. This is the second time in the last 2 weeks that you have followed this nurse and started your day with messy rooms. How would you approach this situation?  54 How would you approach this situation? Would you say nothing and then clean the room up after your colleague went home? Would you mention that the room is a mess and then refuse to hear report until your colleague cleaned up the room? Would you mention that the room is a mess and then tell your colleague not to worry, you will clean it up for them? Would you mention that the room is a mess and then suggest both of you clean it up together? Would you mention that the room is a mess and then discuss solutions to fix the root of the problem?  55 What’s your conflict style? Would you say nothing and then clean the room up after your colleague went home? (Avoidance or Obliging) Would you mention that the room is a mess and then refuse to hear report until your colleague cleaned up the room? (Force or Competition or Domination) Would you mention that the room is a mess and then tell your colleague to not to worry, you will clean it up for them? (Accommodation) Would you mention that the room is a mess and then suggest both of you clean it up together? (Compromise) Would you mention that the room is a mess and then discuss solutions to fix the root of the problem? (Collaboration or Integrating). 56 Conflict Management Styles Avoidance or Obliging: one person uses passive behaviors and withdraws from the conflict; neither person is able to pursue goals, passive. (Lose-Lose) Accommodation: one person puts aside his/her goals in order to satisfy the other person’s desires. (Lose-Win) Force or Competition or Domination: one person achieves his/her own goals at the expense of the other person, aggressive (Win-Lose) Compromise: both people give up something to experience partial goal attainment. (Win/Lose-Win/Lose) Collaboration or Integrating: both people actively try to find solutions that will satisfy them both. (Win-Win) ** Goal is to be able to compromise and collaborate to create solutions that are mutually acceptable and satisfying  57 Cognitive Rehearsal Intellectual therapeutic technique in which one envisions or visualizes an overwhelming or anxiety producing situation. Involves memorizing responses designed to prevent acting impulsively Evidence based approach empowers individuals and gives them a greater sense of self confidence in overcoming barriers to communication Examples: Situation: Nonverbal cue, eye roll Reply: “I sense from your expression that you have something more you’d like to say. Please be direct.” Situation: Withholding of information Reply: “I understand that there may be more information available in this situation. Perhaps there would have been a different outcome had I been informed.”  58 Key Points of Conflict Resolution 1. Identify the problem 2. Recognize how you resolve conflict 3. Have a timely discussion 4. Choose a private location 5. Choose “I” statements, avoid blaming statements 6. Active listening (therapeutic techniques & SOLAR) 7. All people involved must view their conflict as a problem to be solved mutually. 8. Keep the focus on delivery of quality patient care.  59 Conflict Resolution: DESC Script A constructive approach for managing and resolving conflict D—Describe the specific situation or behavior; provide concrete data E—Express how the situation makes you feel/what your concerns are S—Suggest other alternatives and seek agreement C—Consequences should be stated in terms of impact on the established team goal; strive for consensus  60 You are starting out your day shift by obtaining report from the night shift nurse. As you walk in the room, you find it a mess. This is the second time in the last 2 weeks that you have followed this nurse and started your day with messy rooms. Script out your approach to this situation?  61 Example of a conflict Laura: You make me so mad, Donald. Donald: I don’t mean to make you mad. Laura: Well you do. You never think about how I feel. You know I hate it when you leave a patient’s room as cluttered in 103. Donald: You don’t have the vaguest idea what went on here last night! That’s what I hate about you-always so quick to judge. You are so critical. You must think you are perfect!  62 Conflict Resolution D: Laura: Donald, I feel so upset when I find a cluttered room like 103 at the beginning of my shift. E: Laura: I feel as if I am behind when I start and I am worried about patient safety. Donald: I’m really sorry about room 103, Laura. Our shift started with a patient coding right after he arrived from the ER. There was no family here. It took forever to find them and then to support them through the shock. S: Laura: I understand that you were busy. It sounds like there were other priorities. Let’s clean this up now. I would like to set up a time to meet with the QI council to discuss possible solutions on how to keep rooms tidy. Donald: Yes, I think there could be some solutions. C: Laura: Thanks for discussing this me. I will let you know the time of the next QI meeting.  63 Question: Determine whether each of the following actions is a form of lateral or vertical violence. A. Gossiping about another nurse on the unit B. Refusing to help a coworker C. Texting during a meeting with the nurse manager D. Yelling at the assistive personnel E. Rolling eyes when a nurse is giving report F. A supervisor yelling at a staff nurse  64 Question: Determine whether each of the following actions is a form of lateral or vertical violence. A. Gossiping about another nurse on the unit (Lateral) B. Refusing to help a coworker (Lateral) C. Texting during a meeting with the nurse manager (Vertical) D. Yelling at the assistive personnel (Vertical) E. Rolling eyes when a nurse is giving report (Lateral) F. A supervisor yelling at a staff nurse (Vertical)