Learning Objectives
By the end of this section, you will be able to:
- Define collaborative practice
- Understand the components of an effective team structure
- Recall core competencies for collaborative practice
A patient hospitalized for four days may meet fifty different healthcare providers, including a variety of doctors, nurses, assistive personnel (AP), and many additional staff members (O’Keefe, 2020). Each member of this large team must collaborate, or work effectively together, to ensure the patient has the best outcomes possible. No matter a nurse’s role or working environment, every nurse will collaborate with other healthcare workers, stakeholders, patients, and their families. Collaboration is impossible without communication. The two are inextricably intertwined.
Collaboration is so essential to nursing practice that it is the eleventh standard in the American Nursing Association’s (ANA) scope and standards of practice (2021). There are several collaboration competencies expected of all RNs (ANA, 2021, p. 96):
- Work with patients and stakeholders to advocate for and make changes that improve patient outcomes and healthcare quality.
- In every interaction, treat others with dignity and respect.
- Recognize the value of what other stakeholders and professions bring to the table.
- Encourage all team members to contribute their knowledge, skills, and abilities to achieve goals.
- Describe the role of the nurse on interprofessional teams.
- Use tools and informatics to facilitate team processes while maintaining patients’ dignity and respect and following the Health Insurance Portability and Accountability Act protections to ensure their privacy and confidentiality.
- Encourage consensus and conflict management.
- Encourage team-building strategies to improve team or group performance.
- Engage with all stakeholders to develop, execute, and assess plans.
- Role model exemplary team building, leadership, and management when working with teams.
As a new nurse, it can be both reassuring and daunting to realize how important collaboration is to nursing practice. Effective collaboration improves patient outcomes and teamwork between healthcare professionals.
Definition of Collaborative Practice
A collaborative practice, also known as interprofessional or interdisciplinary practice, results from healthcare workers from different professions working and communicating effectively to provide patient care and improve healthcare quality and patient safety. It involves mutual respect and trust, shared decision-making, and effective working relationships (McLaney et al., 2022). It can occur between two or more individuals within the same setting, within and between disciplines, and even over hundreds of miles. Successful collaboration between physicians and nurses improves patient outcomes such as length of stay, mortality, and patient satisfaction (McLaney et al., 2022). It is also linked to increased nurse perception of quality of care.
A 2013 report by The Joint Commission noted that communication issues were the top cause of mortality related to treatment delays (O’Keefe, 2020). Also, communication was found to be the third most common cause of sentinel events. Unfortunately, many healthcare settings have long resisted open and honest communication between all staff. This is mainly because healthcare settings have historically been structured hierarchically, with physicians at the top, creating power imbalances that have negatively impacted communication and, as a result, collaboration. Nurses and other healthcare professionals avoid speaking up and calling out problems for fear of losing their job or experiencing revenge or other forms of discomfort in the workplace (O’Keefe, 2020).
Link to Learning
In 2020, as a response to infection-control issues raised by the COVID-19 epidemic, the Centers for Disease Control and Prevention (CDC), ANA, and over seventy other professional, public health, and educational organizations collaborated in Project Firstline. They aimed to improve the accessibility of infection-control education for all frontline healthcare workers. Explore the website for Project Firstline to see how organizations can collaborate together to address healthcare quality.
Components of Effective Team Structure
A team is a coordinated group of two or more people, each with a specific role, who interact to achieve a common goal. A team structure is the makeup of a single team or a multiteam system, including identification of a team leader and other members. Healthcare teams can be small or large, all at one location or spread out (Agency for Healthcare Research and Quality [AHRQ], 2019). Their goals may be short-term goals: for example, a patient care team forms to provide care for a specific patient and disbands when the patient leaves the organization. In contrast, teams such as quality improvement committees typically have long-term goals.
In the case of patient care teams, team members include anyone involved in that patient’s care. Members of the patient care team are accountable to each other for their actions on the team. They must stay informed and engaged in the process to ensure effective team functioning (AHRQ, 2019). When all members of a care team are present during rounds, for example, patient safety and healthcare quality increase, as does communication between nurses, physicians, and other healthcare team members (Rosen et al., 2018).
Clinical Judgment Measurement Model
Recognize Cues: Including the Patient and Family in Team Structure
While no patient care team can be complete without including the patient and their family, as applicable, it is often difficult to know how to involve these crucial members effectively. Try some of these strategies to encourage their participation in team processes:
- Ask how involved they want to be in the patient’s care.
- Ask about their concerns before beginning discussions of their status, to ensure they can best listen when needed.
- As much as possible, speak in plain language without the use of medical jargon, and explain jargon that cannot be avoided.
- Encourage family members to ask questions.
- Provide additional education and resources for relevant information.
- Ask patients for feedback and encourage them to participate.
Patient responsibilities differ from those of clinicians. Patients are accountable for being honest and accurate when providing information, speaking up if they are concerned about a proposed plan of care, complying with a plan of care if they agreed to it, and reporting any change in their condition in a timely fashion.
(Adapted from AHRQ, 2019.)
Most nurses are members of multiple teams every time they come to work. For each of their patients, they are members of a patient care team that also includes the patient and their family, their provider or prescribing staff member, and additional providers and healthcare workers as needed. Nurses are also members of contingency teams that come together for specific, often emergent, events such as codes, disasters, or rapid response issues.
Healthy teams have a clear structure and work together to enhance patient safety and healthcare quality. High-performing teams also share some important principles that bind them together, including the following (AHRQ, 2019; McLaney et al., 2022):
- role clarity
- shared goals and vision
- mutual respect, trust, and support
- effective communication
- measurable outcomes and processes
Effective Leadership
Teams cannot hold together without effective leadership (AHRQ, 2019). Any professional member of a healthcare team can serve as the team leader if they have the knowledge and skills to achieve the team’s goals (AHRQ, 2019). On the best teams, no matter who the leader is, all members are skilled collaborators adept at encouraging each other to share their expertise.
Team leaders do need to perform a few specific tasks. Leaders must ensure all members are familiar with their roles and responsibilities, set up and monitor the care plan, keep the team on task, model appropriate behavior, and hold members accountable for performing their roles (AHRQ, 2019). Leaders also need to be able to run a team meeting and ensure everyone has the opportunity to be heard. Leaders also need to be able to help members get the resources they need, provide feedback to team members, ensure a strategy to communicate is in place, and assist with conflict resolution.
Interdependent and Adaptive Interactions
Teams interact in a variety of ways. Internally, team members and their roles shift occasionally; even the leadership may change based on the group’s needs (AHRQ, 2019). In a high-functioning team, the team member with the skills most closely aligned to the task at hand will often lead the team while that task is performed. Team members should be able to openly share information within a team without criticism. Regardless of who leads, each member should feel comfortable monitoring the situation and sharing their insights with the entire team, without fear of criticism.
Team members should recognize each other’s limitations and provide support when needed, each from the framework of their respective expertise (AHRQ, 2019). Teamwork failures occur when individuals fail to share information with the team, do not ask for information they need, or fail to include the patient or their family in discussions (AHRQ, 2019). Other failures occur when teams do not adequately use available resources or plan based on unavailable resources, or when individuals do not know and understand the plan or are not told that the plan has changed.
Clear Roles and Responsibilities
Each team member should perform their job on the team and trust the other members to perform their jobs (American Association of Critical-Care Nurses, n.d.). This requires team members to have clear roles and responsibilities and complementary skills that are similar enough to work well together but not identical (McLaney et al., 2022). Each member must also be aware of their role and the roles and responsibilities of the other team members. The larger the team, the more difficult it may be to manage. However, if each member is aware of their own roles and responsibilities, then ongoing team management is easier.
Desire for Common Goals
A shared vision and common goals are characteristics of high-performing teams. When working with patients, the team’s work must be organized around the patient and their family’s goals (American Association of Critical-Care Nurses, n.d.). This patient-centered approach to setting goals allows the healthcare team to align its goals with the needs and abilities of the patient rather than the wishes of the healthcare professionals. At the same time, it allows the healthcare team to be sure the patient is aware of the various strategies the team can use to assist in their care.
As teams work toward their goal, they should regularly evaluate the situation to determine whether they are still heading in the correct direction or if the goal needs to change (McLaney et al., 2022). Consider again the example of a patient care team. When a patient is in the hospital, the patient care team typically meets daily to determine their progress toward meeting their goals, explore any new information that has come up, and ensure all team members remain focused on the goals that matter to the patient.
Patient Conversations
Using Shared Decision-Making and Collaboration with a Patient
Scenario: Mr. Rosenburg, a 50-year-old, has been admitted to the hospital with a diabetic foot ulcer and possible osteomyelitis on his right heel. He is meeting with his care team, including Dr. Blalock, Dr. Eboko, and Nurse Rosa.
Dr. Blalock: Mr. Rosenburg, I’m Dr. Blalock, the attending in charge of your case. Do you understand why they wanted to admit you to the hospital?
Patient: I came in because of this sore on my right heel. I can’t get it to heal, and it’s getting hard to walk so I can’t work. I don’t feel my feet very well, because of my diabetes, and apparently it was worse than I realized.
Dr. Blalock: Yes, you have a diabetic foot ulcer. It’s fairly common for people with diabetes to have injuries to feet that don’t heal well. Yours has gotten quite bad and become infected. We are concerned that the infection has spread to the bone of your heel.
Patient: The doctor downstairs in the emergency room said something about that infection. He had a name for it. . . . I don’t remember. Anyway, how can we fix it? I need to be able to work.
Dr. Eboko: I’m Dr. Eboko, I work with Dr. Blalock. It’s called osteomyelitis, which is a fancy way of saying a bone infection. I will be honest with you: it is difficult to treat and may take some time.
Patient: I don’t have a lot of time, but I guess I have to have this treated. My father lost both of his feet by the time he was sixty. What is the best thing to do, doc?
Dr. Blalock: Well, I would like to run some additional tests and take a couple of wound cultures so that we know we are using the right antibiotics. Then I would like to start you on antibiotics and wound care. You will need to stay here for two weeks to see if the antibiotics work. If all is well, we should be able to discharge you then.
Patient: And if the antibiotics do not work?
Dr. Blalock: Then, assuming you do have osteomyelitis, we would have to consider a surgical option to cut out the infected pieces of your bone.
Patient: Would I lose my foot?
Dr. Blalock: I am not sure. Hopefully not. The surgeon would do their best to leave enough intact bone that you could still walk if possible. But we are not ready for the surgeon yet. Are you okay with running some tests and starting the IV antibiotics?
Patient: Yes. My daughter is getting married in two months, and I need to walk her down the aisle.
Nurse: Oh, that is exciting, Mr. Rosenburg! I will be back in just a few minutes to draw those labs, swab that wound, and dress your foot. Dr. Blalock, are you also going to order some imaging, and could you please put in some orders for wound care and maybe a consult for the wound care nurse?
Dr. Blalock: I sure will. Mr. Rosenburg, you’re in great hands with Nurse Rosa. Do you have any other questions for me right now?
Personal Accountability
Accountability is one reason why effective teams outperform individuals (Zajac et al., 2021). Rather than one individual managing everything, each team member handles their role within the team and is accountable to the other members when they do not (McLaney et al., 2022; Zajac et al., 2021). At the same time, team members must be able to ask questions and request help if needed. Communication must be transparent, and members must serve with honesty and discipline. Teamwork requires members to recognize that personal accountability involves a willingness to be open about what is owed to others and to practice self-management in meeting one’s obligations as part of the team (Peteet et al., 2023).
Link to Learning
This video about using TeamSTEPPS from the AHRQ’s TeamSTEPPS page offers an example of how teams work. It shows clear communication and roles and illustrates how the team can expand or shrink based on the patient’s needs.
Core Competencies for Collaborative Practice
Moving healthcare culture from hierarchical to collaborative practice has taken substantial planning and careful execution. Historically, schools of health professionals, such as nursing schools, have been governed solely by their own national associations (such as the American Association of Colleges of Nursing, the Association of American Medical Colleges, and the American Dental Education Association). These national associations lead the development of curriculum standards and competencies for professional healthcare provider education. For example, the 865 nursing schools that belong to the American Association of Colleges of Nursing use the association’s curriculum standards to develop their own nursing programs (American Association of Colleges of Nursing, 2023). This level of coordination creates consistency across programs, allowing all RNs to use the same NCLEX examination for licensing.
Interprofessional Education Collaborative
In 2009, the Interprofessional Education Collaborative (IPEC)—a partnership between the American Association of Colleges of Nursing and associations for medical, dental, public health, osteopathic, and pharmacy education—was established to develop collaborative education competencies for all healthcare professionals. These became the IPEC Core Competencies for Interprofessional Collaborative Practice (McKearney, 2022). Their aim is to ensure that everyone earning a degree from a healthcare program can perform in collaborative teams immediately upon graduation. Today IPEC has twenty-one association members; it published the third version of its core competencies in 2023.
Interprofessional Education Collaborative Core Competencies
The IPEC core competencies fall into four categories: values and ethics, roles and responsibilities, communication, and teams and teamwork (IPEC, 2023b). Keep in mind that IPEC’s definition of teams includes patients, caregivers, community members, healthcare professionals and stakeholders, and was influenced by team science, a collaborative effort to address a scientific challenge by engaging the strengths of team members with different areas of expertise. IPEC also emphasizes the importance of cultural humility, which encompasses both the ability to self-reflect on one’s background and culture and the willingness to learn from team members of other cultures. Table 15.4 explores the IPEC competencies further.
| Competency Category | Explanation | Examples |
|---|---|---|
| Values and ethics | These eleven competencies emphasize the need for all healthcare professionals to “maintain a climate of shared values, ethical conduct, and mutual respect” as they collaborate. |
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| Roles and responsibilities | These five competencies emphasize the need for all healthcare providers to use their professional expertise and that of their team members to improve health outcomes. |
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| Communication | These seven competencies emphasize the need for respectful, responsible, and compassionate communication between all team members. |
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| Teams and teamwork | These ten competencies emphasize the need to collaborate and engage the strengths of team members with different areas of expertise. |
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Link to Learning
Check out Core Competencies for Interprofessional Collaborative Practice to find out more about the IPEC competencies.