Read: Professional Communication and Team Collaboration that is attached (for more information on this book chapter go to:
https://www.ncbi.nlm.nih.gov/books/NBK2637/
After reading, consider the following:
Why is it important that an organization have a standardized communication tool?
Do clinicians need to employ specific communication techniques to assure patient safety?
Why is communication recognized as a one of the leading causes for a Sentinel Event?
How have you experienced communication in a team or organization setting?
Are all communication tools equal or are they situational? Be specific in explaining your response.
Chapter 33. Professional Communication and Team
Collaboration
Michelle O’Daniel, Alan H. Rosenstein
Background
In today’s health care system, delivery processes involve numerous interfaces and patient
handoffs among multiple health care practitioners with varying levels of educational and
occupational training. During the course of a 4-day hospital stay, a patient may interact with 50
different employees, including physicians, nurses, technicians, and others. Effective clinical
practice thus involves many instances where critical information must be accurately
communicated. Team collaboration is essential. When health care professionals are not
communicating effectively, patient safety is at risk for several reasons: lack of critical
information, misinterpretation of information, unclear orders over the telephone, and
overlooked changes in status.1
Lack of communication creates situations where medical errors can occur. These errors
have the potential to cause severe injury or unexpected patient death. Medical errors,
especially those caused by a failure to communicate, are a pervasive problem in today’s health
care organizations. According to the Joint Commission (formerly the Joint Commission on
Accreditation of Healthcare Organizations, JCHAO), if medical errors appeared on the National
Center for Health Statistic’s list of the top 10 causes of death in the United States, they would
rank number 5—ahead of accidents, diabetes, and Alzheimer’s disease, as well as AIDS, breast
cancer, and gunshot wounds.1 The 1999 Institute of Medicine (IOM) report, To Err Is Human:
Building a Safer Health System, revealed that between 44,000 and 98,000 people die every year
in U.S. hospitals because of medical errors.2 Even more disturbing, communication failures are
the leading root cause of the sentinel events reported to the Joint Commission from 1995 to
2004. More specifically, the Joint Commission cites communication failures as the leading root
cause for medication errors, delays in treatment, and wrong-site surgeries, as well as the second
most frequently cited root cause for operative and postoperative events and fatal falls.1
Traditional medical education emphasizes the importance of error-free practice, utilizing
intense peer pressure to achieve perfection during both diagnosis and treatment. Errors are
therefore perceived normatively as an expression of failure. This atmosphere creates an
environment that precludes the fair, open discussion of mistakes required if organizational
learning is to take place. In the early 1990s, Donald Berwick wrote about patients needing an
open communication system instead of experiencing adverse events stemming from
communication failures.3 More than a decade later, this concept still has profound
implications on our method of health care delivery. As such, this chapter will review the
literature on the important role of communication and team collaboration in helping to
reduce medical errors and increase patient safety.
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Research Evidence
What Are Communication and Team Collaboration?
Webster’s Dictionary defines communication as “the imparting or interchange of thoughts,
opinions, or information by speech, writing, or signs.” It is important to consider that
communication is not just verbal in form. One study states that 93 percent of communication is
more affected by body language, attitude, and tone, leaving only 7 percent of the meaning and
intent based on the actual words said.4 Whereas the spoken words contain the crucial content,
their meaning can be influenced by the style of delivery, which includes the way speakers stand,
speak, and look at a person.1 However, critical information is often transmitted via handwritten
notes, e-mails, or text messages, which can lead to serious consequences if there is
miscommunication.
Collaboration in health care is defined as health care professionals assuming complementary
roles and cooperatively working together, sharing responsibility for problem-solving and making
decisions to formulate and carry out plans for patient care.5, 6 Collaboration between physicians,
nurses, and other health care professionals increases team members’ awareness of each others’
type of knowledge and skills, leading to continued improvement in decisionmaking.7
Effective teams are characterized by trust, respect, and collaboration. Deming8 is one of
the greatest proponents of teamwork. Teamwork, he believes, is endemic to a system in which all
employees are working for the good of a goal, who have a common aim, and who work together
to achieve that aim. When considering a teamwork model in health care, an interdisciplinary
approach should be applied. Unlike a multidisciplinary approach, in which each team member is
responsible only for the activities related to his or her own discipline and formulates separate
goals for the patient, an interdisciplinary approach coalesces a joint effort on behalf of the patient
with a common goal from all disciplines involved in the care plan. The pooling of specialized
services leads to integrated interventions. The plan of care takes into account the multiple
assessments and treatment regimens, and it packages these services to create an individualized
care program that best addresses the needs of the patient. The patient finds that communication is
easier with the cohesive team, rather than with numerous professionals who do not know what
others are doing to mange the patient.9 Table 1 is a compilation of some of the components found
in the literature of a successful teamwork model.10–14
It is important to point out that fostering a team collaboration environment may have hurdles
to overcome: additional time; perceived loss of autonomy; lack of confidence or trust in
decisions of others; clashing perceptions; territorialism; and lack of awareness of one provider of
the education, knowledge, and skills held by colleagues from other disciplines and professions.15
However, most of these hurdles can be overcome with an open attitude and feelings of mutual
respect and trust. A study determined that improved teamwork and communication are described
by health care workers as among the most important factors in improving clinical effectiveness
and job satisfaction.16
Table 1. Components of Successful Teamwork
•
•
•
•
Open communication
Nonpunitive environment
Clear direction
Clear and known roles and tasks for team members
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•
•
•
•
•
•
•
•
•
Respectful atmosphere
Shared responsibility for team success
Appropriate balance of member participation for the task at hand
Acknowledgment and processing of conflict
Clear specifications regarding authority and accountability
Clear and known decisionmaking procedures
Regular and routine communication and information sharing
Enabling environment, including access to needed resources
Mechanism to evaluate outcomes and adjust accordingly
Extensive review of the literature shows that communication, collaboration, and teamwork
do not always occur in clinical settings. For example, a study by Sutcliff, Lewton, and
Rosenthal17 reveals that social, relational, and organizational structures contribute to
communication failures that have been implicated as a large contributor to adverse clinical
events and outcomes. Another study shows that the priorities of patient care differed between
members of the health care team, and that verbal communication between team members was
inconsistent.16 Other evidence shows that more than one-fifth of patients hospitalized in the
United States reported hospital system problems, including staff providing conflicting
information and staff not knowing which physician is in charge of their care.18 Over the past
several years, we have been conducting original research on the impact of physician and nurse
disruptive behaviors (defined as any inappropriate behavior, confrontation, or conflict, ranging
from verbal abuse to physical or sexual harassment) and its effect on staff relationships, staff
satisfaction and turnover, and patient outcomes of care, including adverse events, medical errors,
compromises in patient safety, poor quality care, and links to preventable patient mortality.
Many of these unwanted effects can be traced back to poor communication and collaboration,
and ineffective teamwork.19–22
Unfortunately, many health care workers are used to poor communication and teamwork, as
a result of a culture of low expectations that has developed in many health care settings. This
culture, in which health care workers have come to expect faulty and incomplete exchange of
information, leads to errors because even conscientious professionals tend to ignore potential red
flags and clinical discrepancies. They view these warning signals as indicators of routine
repetitions of poor communication rather than unusual, worrisome indicators.23
Although poor communication can lead to tragic consequences, a review of the literature also
shows that effective communication can lead to the following positive outcomes: improved
information flow, more effective interventions, improved safety, enhanced employee morale,
increased patient and family satisfaction, and decreased lengths of stay.1, 24–26 Fuss and
colleagues27 and Gittell and others28 show that implementing systems to facilitate team
communication can substantially improve quality.
Effective communication among staff encourages effective teamwork and promotes
continuity and clarity within the patient care team. At its best, good communication encourages
collaboration, fosters teamwork, and helps prevent errors.
Barriers to Effective Communication
Health professionals tend to work autonomously, even though they may speak of being part
of a team.29 Efforts to improve health care safety and quality are often jeopardized by the
communication and collaboration barriers that exist between clinical staff. Although every
organization is unique, the barriers to effective communication that organizations face have
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some common themes. Table 2 indicates some common barriers to interprofessional
collaboration that we have learned from our research and focus groups with hospitals across the
country.
Table 2. Common Barriers to Interprofessional Communication and Collaboration
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Personal values and expectations
Personality differences
Hierarchy
Disruptive behavior
Culture and ethnicity
Generational differences
Gender
Historical interprofessional and intraprofessional rivalries
Differences in language and jargon
Differences in schedules and professional routines
Varying levels of preparation, qualifications, and status
Differences in requirements, regulations, and norms of professional education
Fears of diluted professional identity
Differences in accountability, payment, and rewards
Concerns regarding clinical responsibility
Complexity of care
Emphasis on rapid decisionmaking
The barriers indicated in Table 2 can occur within disciplines, most notably between
physicians and residents, surgeons and anesthesiologists, and nurses and nurse managers.30, 31
However, most often the barriers manifest between nurses and physicians. Even though doctors
and nurses interact numerous times a day, they often have different perceptions of their roles and
responsibilities as to patient needs, and thus different goals for patient care. One barrier
compounding this issue is that because the United States is one of the most ethnically and
culturally diverse countries in the world, many clinicians come from a variety of cultural
backgrounds. In all interactions, cultural differences can exacerbate communication
problems.1 For example, in some cultures, individuals refrain from being assertive or
challenging opinions openly. As a result, it is very difficult for nurses from such cultures to
speak up if they see something wrong. In cultures such as these, nurses may communicate
their concern in very indirect ways. Culture barriers can also hinder nonverbal
communication. For example, some cultures ascribe specific meaning to eye contact,
certain facial expressions, touch, tone of voice, and nods of the head.
Issues around gender differences in communication styles, values, and expectations are
common in all workplace situations. In the health care industry, where most physicians are male
and most nurses are female, communication problems are further accentuated by gender
differences.32
A review of the organizational communication literature shows that a common barrier to
effective communication and collaboration is hierarchies.33–37 Sutcliff and colleagues’ research17
concurs that communication failures in the medical setting arise from vertical hierarchical
differences, concerns with upward influence, role conflict, and ambiguity and struggles with
interpersonal power and conflict. Communication is likely to be distorted or withheld in
situations where there are hierarchical differences between two communicators, particularly
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when one person is concerned about appearing incompetent, does not want to offend the other, or
perceives that the other is not open to communication.
In health care environments characterized by a hierarchical culture, physicians are at the top
of that hierarchy. Consequently, they may feel that the environment is collaborative and that
communication is open while nurses and other direct care staff perceive communication
problems. Hierarchy differences can come into play and diminish the collaborative interactions
necessary to ensure that the proper treatments are delivered appropriately. When hierarchy
differences exist, people on the lower end of the hierarchy tend to be uncomfortable speaking up
about problems or concerns. Intimidating behavior by individuals at the top of a hierarchy can
hinder communication and give the impression that the individual is unapproachable.1, 38
Staff who witness poor performance in their peers may be hesitant to speak up because
of fear of retaliation or the impression that speaking up will not do any good. Relationships
between the individuals providing patient care can have a powerful influence on how and even if
important information is communicated. Research has shown that delays in patient care and
recurring problems from unresolved disputes are often the by-product of physician-nurse
disagreement.39 Our research has identified a common trend in which nurses are either reluctant
or refuse to call physicians, even in the face of a deteriorating status in patient care. Reasons for
this include intimidation, fear of getting into a confrontational or antagonistic discussion, lack of
confidentiality, fear of retaliation, and the fact that nothing ever seems to change. Many of these
issues have to deal more with personality and communication style.40 The major concern about
disruptive behaviors is how frequently they occur and the potential negative impact they can
have on patient care. Our research has shown that 17 percent of respondents to our survey
research in 2004-2006 knew of a specific adverse event that occurred as a result of disruptive
behavior. A quote from one of the respondents illustrates this point: “Poor communication postop because of disruptive reputation of physician resulted in delayed treatment, aspiration, and
eventual demise.”19
Leaders in both medicine and nursing have issued ongoing initiatives for the development of
a cooperative rather than a competitive agenda to benefit patient care.5, 39, 41, 42 A powerful
incentive for greater teamwork among professionals is created by directing attention to the areas
where changes are likely to result in measurable improvements for the patients they serve
together, rather than concentrating on what, on the surface, seem to be irreconcilable professional
differences. The fact that most health professionals have at least one characteristic in common, a
personal desire to learn, and that they have at least one shared value, to meet the needs of their
patients or clients, is a good place to start.
Practice Implications
Known Benefits of Communication and Team Collaboration
A large body of literature shows that because of the complexity of medical care, coupled with
the inherent limitations of human performance, it is critically important that clinicians have
standardized communication tools and create an environment in which individuals can speak up
and express concerns. This literature concurs that when a team needs to communicate complex
information in a short period of time, it is helpful to use structured communication
techniques to ensure accuracy. Structured communication techniques can serve the same
purpose that clinical practice guidelines do in assisting practitioners to make decisions and
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take action. Research from aviation and wilderness firefighting is useful in health care because
they all involve settings where there is a huge variability in circumstances, the need to adapt
processes quickly, a quickly changing knowledge base, and highly trained professionals who
must use expert judgment in dynamic settings. Research shows that in these disciplines, the
adoption of standardized tools and behaviors is a very effective strategy in enhancing teamwork
and reducing risks.1, 17, 43–54, 60, 61
Crew Resource Management (Aviation). Experts in aviation have developed safety
training focused on effective team management, known as Crew Resource Management (CRM).
Improvements in the safety record of commercial aviation may be due, in part, to this training.
Realizing that 70 percent of commercial flight accidents stemmed from communication failures
among crew members, CRM sought to standardize communication and teamwork. The concept
originated in 1979, in response to a NASA workshop that examined the role that human error
plays in air crashes. CRM emphasizes the role of human factors in high-stress, high-risk
environments. John K. Lauber, a psychologist member of the National Transportation Safety
Board, deemed CRM as “using all available sources—information, equipment, and people—to
achieve safe and efficient flight operations.”44, 45 CRM encompasses team training as well as
simulation, interactive group debriefings, and measurement and improvement of aircrew
performance. This represents a major change in training, which had previously dealt with only
the technical aspects of flying. It considers human performance limiters (such as fatigue and
stress) and the nature of human error, and it defines behaviors that are countermeasures to error,
such as leadership, briefings, monitoring and cross-checking, decisionmaking, and review and
modification of plans. From a practical standpoint, CRM programs typically include educating
crews about the limitations of human performance. Trainees develop an understanding of
cognitive errors and how stressors (such as fatigue, emergencies, and work overload) contribute
to the occurrence of errors. Operational concepts stressed include inquiry, seeking relevant
operational information, advocacy, communicating proposed actions, conflict resolution, and
decisionmaking. CRM is now required for flight crews worldwide.
The development and implementation of CRM in aviation over the last 25 years offers
valuable lessons for medical care. Sexton and colleagues51 compared flight crews with operating
room personnel on several measures, including attitudes toward teamwork. This landmark study
included more than 30,000 cockpit crew members (captains, first officers, and second officers)
and 1,033 operating room personnel (attending surgeons, attending anesthesiologists, surgical
residents, anesthesia residents, surgical nurses, and anesthesia nurses). Questionnaires were sent
to crew members of major airlines around the world (over a 15-year period). The operating room
participants were mailed an analogous questionnaire, administered over a period of 3 years at 12
teaching and nonteaching hospitals in the United States, Italy, Germany, Switzerland, and Israel.
The Sexton study and other analyses suggest that safety-related behaviors that have been
applied and studied extensively in the aviation industry may also be relevant in health care.
Study results show successful CRM applications in several dynamic decisionmaking health care
environments: the operating room, labor and delivery, and the emergency room.26, 31, 55, 56 As with
aviation, the medical application of CRM has required tailoring of training approaches to mirror
the areas in which human factors contribute to mishaps. In anesthesiology, 65–70 percent of
safety problems (accidents or incidents) have been attributed at least in part to human error. In
response, several anesthesiologists from the Veterans Affairs Palo Alto Health Care System and
Stanford University developed Anesthesia Crisis Resource Management (ACRM), modeled
on CRM.55 Kaiser Permanente, a nonprofit American health care system providing care for 8.3
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million patients, has also adopted CRM with successful results.54 In response to the occurrence
of a sentinel event—a medical error with serious consequences—Eglin U.S. Air Force (USAF)
Regional Hospital developed and implemented a patient safety program called Medical Team
Management (MTM) that was modeled on the aviation industry’s CRM program and focused on
communication, teamwork, and reporting to determine the impact of a patient safety program on
patterns of medical error reporting.57 This study was a retrospective review of 1,102 incident
reports filed at Eglin USAF Regional Hospital in Florida between 1997 and 2001. Collected data
from the comparison periods (1998 and 2001) were statistically analyzed using the chi-square
test. This study indicates that, since the implementation of MTM, there has been a statistically
significant increase in the number of reports filed at Eglin USAF Regional Hospital and a decline
in the severity of incidents. These findings suggest that since the implementation of MTM, there
have been changes in the patterns of error reporting, and with training, staff are able to prevent
more serious incidents. Table 3 highlights the application of a CRM model to medicine.
Table 3. Application of a CRM Model to Medicine
•
•
•
•
•
Design of systems to absorb errors through redundancy, standardization, and checklists
Movement from placing blame to designing safe processes and procedures, i.e., applying a
systems approach
Assurance of full immunity while implementing a nonpunitive approach
Debriefing of all events, including near misses, that have learning potential. Focus on the
severity of the potential risk rather than on the severity of the event’s final outcome is more
conducive to establishing effective prevention programs.
Institutionalization of a permanent program for risk identification, analysis, and dissemination of
the lessons learned throughout the professional community
Kaiser Permanente, SBAR (Situation, Background, Assessment, Recommendation)
Tool, 2002. Doctors and nurses often have different communication styles in part due to training.
Nurses are taught to be more descriptive of clinical situations, whereas physicians learn to be
very concise. Standardized communication tools are very effective in bridging this difference in
communication styles.
Michael Leonard, physician coordinator of clinical informatics at Kaiser Permanente, along
with colleagues, developed a technique called SBAR (Situation-Background-AssessmentRecommendation). This technique has been implemented widely at health systems such as
Kaiser Permanente.1, 17, 58 Many other hospitals have embraced the SBAR communication tool or
a similar tool created by the Studer Group (see Table 4).59 For example, the Queen’s Medical
Center in Honolulu has incorporated the SBAR tool as a key component of its patient safety
program. The SBAR technique provides a framework for communication between members of
the health care team about a patient’s condition. SBAR is an easy-to-remember tool used to
create mechanisms useful for framing any conversation, especially critical ones, requiring a
clinician’s immediate attention and action. It allows for an easy and focused way to set
expectations between members of the team for what will be communicated and how, which is
essential for information transfer and cohesive teamwork. Not only is there familiarity in how
people communicate, but the SBAR structure helps develop desired critical-thinking skills. The
person initiating the communication knows that before they pick up the telephone, they need to
provide an assessment of the problem and what they think an appropriate solution is. Their
conclusion may not ultimately be the answer, but there is clearly value in defining the situation.
Table 5, Guidelines for Communicating with Physicians Using the SBAR Process explains how
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to carry out the SBAR technique in detail. The guidelines use the physician team member as the
example; however, they can be adapted for use with all other health professionals.
Table 4. Studer Group Communication Guidelines for Nurses
•
•
•
•
•
•
•
•
•
Have I seen and assessed this patient myself before I call?
Are there standing orders?
Do I have at hand
o The chart?
o List of current meds, IV fluids, and labs?
o Most recent vital signs?
o If reporting lab work, date and time this test was done and results of previous tests for
comparisons?
o Code status?
Have I read the most recent MD progress notes and notes from the nurse who worked the shift
ahead of me?
Have I discussed this call with my charge nurse?
When ready to call,
Remember to identify self, unit, patient, room number.
o Know the admitting diagnosis and date of admission.
o Briefly state the problem, what it is, when it happened or started, and how severe it is.
What do I expect to happen as a result of this call?
Document whom you spoke to, time of call, and summary of conversation.
Engage and treat physician with respect.
[Source: Studer Group. Patient Safety Toolkit – Practical tactics that improve both patient safety and patient perceptions of care.
Gulf Breeze, FL: Studer Group., 2007.]
Table 5. Kaiser Permanente, SBAR (Situation, Background, Assessment, Recommendation) Tool,
2002
¾
¾
¾
¾
¾
SBAR – a technique for communicating critical information that requires immediate attention and
action concerning a patient’s condition
Situation – What is going on with the patient?
“I am calling about Mrs. Joseph in room 251. Chief complaint is shortness of breath of new
onset.”
Background – What is the clinical background or context?
“Patient is a 62-year-old female post-op day one from abdominal surgery. No prior history of
cardiac or lung disease.”
Assessment – What do I think the problem is?
“Breath sounds are decreased on the right side with acknowledgment of pain. Would like to rule
out pneumothorax.”
Recommendation – What would I do to correct it?
“I feel strongly the patient should be assessed now. Are you available to come in?”
[Source: Institute for Healthcare Improvement. Guidelines for communicating with physicians using the SBAR process.
http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel
.htm. Accessed Nov. 18, 2004.]
STICC (Situation Task Intent Concern Calibrate) is another type of structured briefing
protocol used by the U.S. Forest Service to give direction to firefighters.1, 17, 60, 61 The
following five steps are involved:
• Situation: Here’s what I think we face.
• Task: Here’s what I think we should do.
• Intent: Here’s why.
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•
•
Concern: Here’s what we should keep our eye on.
Calibrate: Talk to me. Tell me if you don’t understand, can’t do it, or see
something I do not.
Establishing Culture To Support Communication and
Team Collaboration
The literature reviewed shows that effective teams are characterized by common
purpose and intent, trust, respect, and collaboration. Team members value familiarity over
formality and watch out for each other to make sure mistakes are not made. Health care
teams that do not trust, respect, and collaborate with one another are more likely to make a
mistake that could negatively impact the safety of patients.
One of the first crucial steps is organizational commitment and willingness to address the
situation. Commitment needs to come from the top down and bottom up, making a statement
about the way the organization does business. The rallying point should be around behavioral
standards and their relationship to patient safety. It’s ironic that ever since the publication of the
original IOM report, To Err Is Human, organizations have spent the bulk of their time and efforts
in improving patient systems rather than addressing the human factor issues highlighted in the
original report.2 Several recent reports have suggested that while we have made progress in the
patient safety movement, we have a long way to go in meeting the IOM recommendations.62
Addressing defects in communication that affect collaboration, information exchange,
appreciation of roles and responsibilities, and direct accountability for patient care are key
components of any patient safety program. Clinical and administrative leaders must set the tone
by establishing and adhering to behavioral standards that support agreed-upon code of conduct
practices backed by a nonpunitive culture and zero-tolerance policy.
The next step in the process is recognition and self-awareness. Organizations must be able to
assess the prevalence, context, and impact of behaviors to identify potential opportunities for
improvement. Doing an internal assessment will help pinpoint the seriousness of the situation
and provide clues to areas that need to be addressed. Assessment information can be gained from
formal methods such as incident reports, survey tools, focus groups, department meetings, task
forces or committees, direct observation, suggestion boxes, and hot lines. Informal methods such
as casual meetings and gossip can also provide valuable surface information and should be
evaluated more deeply as to the source, relevance, and significance of the events to determine
next steps. In many organizations there are still remnants of reluctance to address the issue head
on for fear of antagonizing a prominent surgeon or staff member. With growing concerns about
workforce shortages, staff satisfaction and retention, hospital reputation, liability and patient
safety, and the need for compliance to the latest Joint Commission proposed standards
addressing disruptive behaviors, organizations can no longer afford to take a passive approach to
the situation.63–66
Creating opportunities for different groups to just get together is a highly effective strategy
for enhancing collaboration and communication. These group interactions can be either formal or
informal. Encouraging open dialogue, collaborative rounds, implementing preop and postop
team briefings, and creating interdisciplinary committees or task forces that discuss problem
areas frequently provides an upfront solution that reduces the likelihood of disruptive events.
When a disruptive event does occur, some organizations have implemented a time-out, code
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white, or red light policy that addresses the issue in real time to prevent any further serious
consequences.59
Developing and implementing a standard set of behavior policies and procedures is vital.
These policies need to be consistent and universally applied. There should not be a separate
policy for any one particular discipline or service. For the medical staff, the policies should
become part of the medical staff bylaws with signed agreements to abide by these policies at the
time of appointment and recredentialing. Included in the policies should be a standardized
protocol outlining expected standards and the process for addressing disruptive behavior issues,
recommendations, followup plans, and actions to be taken in the face of individual resistance or
refusal to comply. Prior to implementation, make sure all employees are familiar with the
existence, purpose, and intent of the policies and procedures.
For the process to unfold, the organization needs to encourage its employees to report
disruptive behaviors. The organization needs to address issues related to confidentiality, fear of
retaliation, and the common feelings that there is a double standard and that nothing ever gets
done. Reporting mechanisms should be made easy and must be supported by the presence of a
nonpunitive environment. The ideal vehicle for reporting is to address the situation in real time,
but concerns about position, appropriateness, receptiveness, fear, hostility, and retaliation are
significant impediments.67 Appropriate vehicles for reporting may include reporting of the
incident to a superior, filing an incident report, using a complaint or suggestion box, or reporting
directly to a task force or interdisciplinary committee with assigned responsibilities for
addressing these issues.59 Besides maintaining confidentiality and reducing risks of retaliation,
one of the most crucial aspects of the reporting system is to give recognition and assurance that
the complaints will be addressed and actions will be taken. Responses should be timely,
appropriate, consistent, and provide necessary feedback and followup.
Taking action though appropriate intervention strategies is next. On one level, generic
educational programs can do a lot to spread the message and teach basic skills necessary to
promote effective communication. Appropriate topics should include sessions on team dynamics,
communication skills, phone etiquette, assertiveness training, diversity training, conflict
management, stress management, and any other courses necessary to foster more effective team
functioning and communication flow. Courses should be offered to all staff and employees at the
organization: physicians, physicians in training, nurses, nursing students, and all other staff who
have patient contact or play a role in the delivery of patient care. For individuals who have
consistently exhibited disruptive behavior, education may need to be supported by more focused
sessions and specific counseling. Another important strategy is to promote and assure
competency training at all levels of the health care team. This is a key factor affecting trust and
respect, which have such a strong influence on team collaboration.
Focused team training programs have been of particular value. One of the newer approaches
to improving team collaboration and patient safety is through the principles learned from the
aviation industry. Fostering an environment of trust and respect, accountability, situational
awareness, open communication, assertiveness, shared decisionmaking, feedback, and education,
interdisciplinary CRM training has brought significant improvements to communication flow in
the perioperative setting.52, 53
Having a clinical champion or early adopter who actively promotes the importance of
appropriate behavior, communication, and team collaboration can be an extremely valuable
asset. Champions can come from the executive ranks or through the voluntary interest and
enthusiasm of other staff members. Co-champions may be even more effective. Some
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organizations have reported that having a nurse and physician (or other health care professional)
go through a joint training program will help foster mutual cooperation and collaboration
between the different disciplines.59 Followup and feedback bring closure to the process. It is
important to let people know that their input is welcomed, followup actions will be taken, and
appropriate feedback will be provided.
Research Implications
The existing literature adequately outlines structured communication techniques that will
help minimize medical errors. However, more research is needed on how to effectively deal
with miscommunication and barriers to communication in real-time crisis situations. Also, the
existing literature lacks concrete research confirming a cause-and-effect relationship between
human factors and clinical outcomes of care.
Conclusions
Effective clinical practice must not focus only on technological system issues, but also on the
human factor. As shown in this chapter, good communication encourages collaboration and helps
prevent errors. It is important for health care organizations to assess possible setups for poor
communication and be diligent about offering programs and outlets to help foster team
collaboration. By addressing this issue, health care organizations have an opportunity to greatly
enhance their clinical outcomes.
Author Affiliations
Michelle O’Daniel, M.H.A., M.S.G., director, member relations, VHA West Coast. E-mail:
modaniel@vha.com.
Alan H. Rosenstein, M.D., M.B.A., vice president and medical director, VHA West Coast. Email: arosenst@vha.com.
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