|Working With an
Eileen Wenckus, RN, MSN, CS
|The goal of this program is to enhance nurses
abilities to work with interdisciplinary teams.
After you study the information presented here, you will be able to
Andrea, an RN, looked forward to the weekly interdisciplinary team meetings on the 20-bed unit of her hospital-based, skilled nursing facility. The eight-member group, comprising a geriatric physician, social worker, dietitian, nurse, and physical, occupational, and activities therapists, includes patients in the formulation and review of care plans. Because patients join the group to discuss their cases only, the members must adhere to a carefully timed agenda. This morning, they all arrive on time as usual.
Andrea discusses the progress of the first patient, Ted, whose goals include ambulating 30 feet on the unit twice a day and performing activities of daily living (ADLs) with minimal assistance from one person. The team members have a stake in his success because they have all personally cared for him. They had planned to discharge Ted to a personal care facility, but today they discover that he has ambulated only three times during the past week less than 20 feet each time and he has only been able to perform ADLs with maximum aid from one to two caregivers. The social worker begins to question the feasibility of the discharge goal, while the physical therapist voices surprise at the poor ambulation, because Ted regularly walks 50 feet in the PT department. But Ted offers his perspective that he is too tired to ambulate after therapy and the very busy nurses asked him to walk at the worst times. He states that they become impatient and do things for him before he has a chance to do them for himself.
Rather than reacting defensively or personally, Andrea attacks the problem. As a nurse, she knows that Ted may feel frustrated, tired, and not in control. She asks him, When are the best times for walking on the unit? Which activities do you need more time for? Ted gives surprisingly motivated answers, stressing his wishes to go to a personal care facility. In fact, his enthusiasm persuades the group. The physical and occupational therapists agree that the goal is realistic; the social worker reverses his questioning the goal, promising to continue with the original placement plan.
If the team members had not met, a satisfactory conclusion may not have been reached. If the nurse had reacted negatively, the patients wishes might have been subjugated to personal agendas. Without the skilled input of the team players, the outcome might have been very different. Although each professional brought a unique perspective to the meeting, they shared a common set of team skills. Your team can achieve the same degree of effectiveness with practice.
An emphasis on teamwork has recently emerged in healthcare and business as organizations retool for more flexibility and efficiency. Managers have had to abandon autocratic, top-down controlling styles1 and place responsibilities for making work decisions in the hands of their staff.
The current trend of using teams in healthcare organizations can lead to more comprehensive patient care and a reduction in costs.1,2 Teamwork helps to improve decision-making, which has often been hampered by traditional, multiple layers of management and extensive (and sometimes, over-) specialization. Hospitals, in particular, have had long chains of command that often separated primary decision-makers, top administrators, from patient care, the work of the institution. Even at the bedside, the care of professional providers may be so specialized and autonomous that it becomes isolated and uncoordinated with the efforts of colleagues from other disciplines. For example, in the past, practitioners from various services might have developed separate plans of care for the same patient, and much of the communication between them only occurred by reading each others written progress notes. Because such practice contributed to fragmented care, duplicated services, and the exclusion of patients input1 into their own care, hospitals have moved toward team-building.
Nursing and other healthcare disciplines have periodically reported on the benefits of teamwork for patient care as early as 1922.3 At different points in your career, you may have encountered the team nursing approach to patient care, coordinated patient assignments through a primary care model, or participated in a group process on a hospital committee, such as an ethics committee. Teams pervade all healthcare settings, especially nursing homes and hospital-based nursing facilities, where interdisciplinary care planning is mandated.4 Current Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) standards reinforce these traditions by emphasizing interdisciplinary care planning in hospitals as well.5 The American Nurses Association also cites collaboration among the patient, healthcare providers, and the family for care plans and professional performance in its Standards of Clinical Nursing Practice.6
The Interdisciplinary Team
Multidisciplinary and interdisciplinary team designations, often used interchangeably, refer to different groups in healthcare. A multidisciplinary team comprises members from a variety of disciplines, each providing separate, discipline-oriented input to a team leader who processes the information and makes decisions about care. A interdisciplinary team is also composed of members from various practices, but members pool information to arrive at a consensus.1 A similar distinction differentiates a working group and a team. The dynamics in a working group emphasizes individual contributions of the members, while a team stresses collective results.8
An interdisciplinary team focuses on outcomes, recognizing that the participants share responsibility for achieving them.3 The leadership of the team may rotate among its associates, depending on the skills needed at a particular time, or be completely shared. The role of the leader, when it is utilized, is to facilitate, rather than direct, the collective work.7 In one instance, as a collective entity, the participants may take responsibility for all operations, including their own work schedule, budget, and supplies. These interdisciplinary teams are called self-directed work groups in the field of business, where they have helped to reduce costs. In healthcare, improvements in communication alone could have a similar effect by reducing duplication of services and length of stay.
How Effective Teams Work
You might have worked with a group that never seemed to get anything accomplished. After a nonproductive meeting, you might have come away wondering how the meeting time could have been used more efficiently. There are common behaviors that ensure effective team functioning.
Set clear goals. Written goals need to be defined within the first few contacts at special meetings to focus individuals efforts toward achieving the groups purpose. Goals help to clarify direction for future actions. Be sure to set up deadlines for accomplishing tasks and be clear about who is responsible.
Evaluate progress. Establish a process for periodic evaluation of the work in terms of the goals. Schedule separate meetings to accomplish this.
Plan ahead. Always have an agenda for meetings and stick to it.
Take advantage of individual talents. Become adept at recognizing and using individual members strengths to accomplish the goals. Effective teams also learn to publicly recognize the special contributions that each team member makes for the common purpose.
Clarify roles. Role conflict is not uncommon and can stem from unclear assignments and/or preconceived ideas about our own or others roles and responsibilities.3 For example, a nurse may have rigid ideas about a social workers role that conflict with the social workers own perceptions about his or her professional identity. Clear work assignments, developed early by the team, can diminish role conflict, ambiguity, and overlap.
Share the leadership. Although one members skills or ideas may cause that individual to come to dominate a particular task, leadership of the team is the responsibility of all team participants. And whenever an individual assumes formal leadership, the role should be to help the group achieve common goals.
Although nurses can make valuable contributions to interdisciplinary efforts, many come to the group with few of the needed skills and little knowledge of how to participate effectively in this situation. Nurses may not even realize that they need to work differently when participating on a team.7 These deficits can delay the work of the group and divert valuable time and energy to helping potential members from various professions acquire skills necessary to work together. An understanding of these skills before participating on an interdisciplinary team will enhance the productivity of teams in which you participate by shortening learning time so you can get right to work. These skills will also improve your ability to work with colleagues from your own discipline in everyday work.
Team-building skills are competencies that enable a group to work together effectively. Team players need to acquire expertise in communication,8 conflict negotiation and resolution,9 and consensual decision-making.8
Communication: Little teamwork can take place without open, assertive communication among its members. When you come to meetings, you can encourage the free exchange of ideas by sharing your opinions. On the other hand, you need to be willing to listen to the suggestions of others. Feedback needs to be constructive and directed at issues, not people. Criticism that is perceived to be personal will most likely discourage open communication and the effective participation of other professionals. Team members who feel comfortable in sharing thoughts, asking questions, and discussing options together are more likely to arrive at effective outcomes.
Conflict: Conflict can occur whenever people of differing skill levels, backgrounds, and opinions are brought together. Disagreement is a normal part of working together, but original ideas may result when professionals pool their diverse backgrounds and the perspectives of their disciplines. If all team members only consider problems from a homogeneous viewpoint, opportunities for creative solutions may be lost.9 Effective team members accept conflict as normal in organizations and perceive that a variety of approaches to problem-solving enhances the likelihood that they will be solved.
Decision-Making: Individuals need to become adept at working with the group to arrive at mutual decisions. Because professionals often work independently and make decisions autonomously, they may not be used to participating in group decision-making.7 You can improve your skills by listening to the options offered by others, while focusing on the goals. This can help in recognizing the best and most appropriate choices for the team. A team decision is consensual and reflects the full membership of the group.10 Try to avoid voting (where there are always losers) or easy compromise, and look for win-win situations.
Reaching agreement by consensus is dependent upon everyones participation and effective teams encourage this. Mutual trust among professionals encourages open decision-making and discourages the conflict that comes from adversarial coalitions. Sometimes you need to be the first one to risk voicing an opinion to elicit thoughts from others. Positive reinforcement when others share the same risk can go a long way toward helping them feel comfortable and strengthening trust among the group. Finally, once agreement has been reached, the team needs to take full responsibility for the decision and its outcome.
Managements Work with the Team
Managers, supervisors, and directors can become facilitators and coaches when teams enter the workplace.9,7,11 A facilitator acts as a resource, an advocate, and a liaison.9 As a resource, the facilitator provides information and clarification, for example, regarding the institutions policies and procedures. In an advocate role, the facilitator markets the work of the team with administration and promotes its decisions. A facilitator does not usually participate in making decisions, but rather enhances the groups efforts from the sidelines, refocusing discussions when necessary. The liaison role involves conveying information from the group to administration. The facilitator also becomes a liaison for the group with other teams and departments that may lend vital support to the memberships work.
A complementary quality that can enhance the role of the facilitator is a sense of humor. A good joke, a laugh, or a smile can relieve tension and bring things back into focus. Humor, like positive reinforcement, promotes good feelings and creates the relaxed atmosphere needed for the team to work at its best.
Regardless of your membership, its helpful to know that learning to work together as a team takes skill and practice. Even astronauts work together every day for a year before flying a mission together.7 With some practice and skill development, youll become an effective team member more quickly and help your team work to its potential.
Editors Note: If you would like to earn continuing education credits for this article, you can obtain the posttest by going online to Self-Study Modules or calling the Nursing Spectrum Division of Continuing Education at (800) 866-0919.