Teamwork and collaboration

•Other strategies to prevent conflict

-Address issues as they arise -Avoid destructive criticism -Treat others with respect -Avoid arguments -Actively listen to each other -Consider others' points of view, including cultural beliefs and values

intergroup conflict

-Between teams in competition or opposition to one another

interpersonal communication

-Between two or more people -Can arise from differences in goals or personalities, competition, concern about territory, control, loss

intraorganizational process

-Between two organizations within one market

•Characteristics of effective interprofessional communication

-Common purpose and goals identified at outset -Clinical competence of each provider -Interpersonal competence -Humor -Trust Valuing and respecting diverse, complementary knowledge

•Nurses must do what to prevent conflict?

-Communicate clearly to prevent misunderstanding -Be able to identify potential issues -Manage their own tension or stress level ▪Mindsight: being self-aware of one's triggers to stress that can result in conflict, purposefully retraining brain to respond differently

•Close nature of relationship allows little room for conflict

-Conflicts with patients or with family members/caregivers can still arise

•Victims of bullying experience adverse emotional effects

-Depression -Anxiety -Sense of isolation

•Interprofessional Education Collaborative

-Interprofessional communication is one of four core competencies as framework for collaboration and practice ▪The others: values & ethics, roles & responsibilities, teams & teamwork

•Causes of conflict

-Lack of knowledge on part of patient or family member(s) -Poor coping skills on part of patient or family member(s) -Fear or anxiety → patient or family member expressing frustration -Failure of nurse to assess or meet patient needs -Failure of nurse to promote therapeutic relationship

•Conflict

-Occurs when diverse interests about significant issues or concerns among individuals, groups, or organizations prevent problem solving, or emotional opposition creates discord, stifles effective communication -A normal part of work environment -Cannot be eliminated in an organization -Can be managed •Responses to conflict depend on nurse's leadership skills •Although viewed as negative, conflict can be impetus for better communication, stronger team relationships, healthy changes

•Positive psychosocial, professional effects

-Patients, nurses have greater sense of autonomy

•Processes associated with these characteristics

-Recurring interactions that develop connections, mutual respect and trust among healthcare professionals -Interpersonal skills, respect for competence of all collaborators

•Besides strategies already presented, manage conflict by

-Setting limits -Never allowing patients or families to demonstrate anger inappropriately -Considering cultural differences ▪Language barriers ▪Whether culture considers it appropriate to be very emotional -Active listening, clear communication

•Abusive behavior is never acceptable

-Tolerance of acts of aggression may lead to escalation -Inappropriate demonstrations of anger should be reported immediately to team leader or charge nurse

intrapersonal communication

-Within an individual -Stress, tension resulting from real or perceived pressure generated by incompatible expectations or goals

overt conflict

Addressed openly Obvious to most individuals Easier to arrive at agreement that conflict is present, description of conflict

Incivility in workplace may take many forms

Aggression Bullying Violence

For individuals in leadership roles, strategies to promote conflict prevention

Allocate resources fairly, including fair distribution of workload balance and intensity Clearly define role expectations for all team members Encourage staff to provide feedback, identify potential concerns without threat of punitive action Acknowledge team members' accomplishments, achievements, significant life events

Effective responses

Be honest, trustworthy, respectful State issues objectively, provide factual basis for concern Avoid emotion-based discussions Be open to hearing all viewpoints, avoid passing judgment Do not interrupt when individuals express concerns Use active listening techniques Focus on identifying solutions rather than worsening problem Keep delivery of safe, effective client care as central concern

Types of Conflict

Between individual nurses between nurses and patients or family members Between nurses and other members of healthcare team Within a unit Within a department Between units or departments Between multiple organizations Between or within teams or units Between organization and community

Benefits of interprofessional collaboration

Collaboration has system-wide effects World Health Organization (WHO) links interprofessional collaboration with improved patient outcomes Collaborative approach ideally benefits patients, professionals, and the healthcare delivery system Because care becomes patient centered and patient directed Patients empowered as informed consumers, actively collaborate with healthcare team in decision-making process Quality of care improves, everyone ultimately benefits Adherence to therapeutic regimens increases Lengths of stay decrease Overall costs to system decline Sound application of collaborative strategies → decreased patient morbidity, mortality Collegial relationships, improved overall job satisfaction

Decision Making

Collaboration involves shared responsibility for outcome Team decision making must be directed at objectives of the specific effort Starting with clear definition of the problem Facilitated by mutual respect and timely, effective feedback Requires healthcare team to focus on patient's priority needs, organize interventions accordingly Discipline best able to address patient's needs Identified Given priority in planning Held responsible for providing interventions in timely manner Nurses often able to help team identify priorities, areas needing further attention Ideally, the team ensures that patient is part of decision-making process

The Nurse as Collaborator?

Collaboration may occur Between nurses Between healthcare providers and patients Between healthcare providers from different professional backgrounds

Parallel functioning

Communication more coordinated, but each professional has separate interventions, separate plan of care

Communication is key for resolving conflict Five communication styles?

Competing: assertive, power-oriented approach Collaborating: cooperative approach Compromising: approach in which both parties are partially satisfied Avoiding: uncooperative approach Accommodating: attempt to satisfy others' needs while neglecting own Ability to move among styles to suit situation takes practice, awareness of self

Negativity can lead to adverse organizational outcomes

Decreased job satisfaction Absenteeism Loss of productivity Patient errors with potential for adverse outcomes Associated costs of staff turnover or legal fees

Fundamental components of therapeutic relationship

Demonstrating respect Being self-aware Maintaining boundaries within the team Being empathetic Accepting individuality Promoting equality among team members These qualities lay groundwork for approaching communication about patient problems as in a relationship Moving from "I" statements to "how best can we" conversations

Parallel Communication

Each provider communicates with patient independently, similar questions

Institution-wide programs that

Emphasize respect Acknowledge communication for sake of patient safety Use nondisciplinary approaches to resolve issues Model language and tactics that remove barriers to conflict resolution Examples: Crucial Conversations Crew Resource Management TeamSTEPPS The Exchange

Concepts Related to Collaboration

Health Policy Healthcare Systems Professional Behaviors Quality Improvement Safety

Using relational approach?

Helps individuals understand their own responses to conflict Can improve care coordination → better clinical outcomes

competencies basic to collaboration

Mutual respect Trust Effective communication skills Giving and receiving feedback Decision making Conflict management

Quality and Safety Education for Nurses (QSEN) project

Identified teamwork and collaboration as two of the six competencies needed to achieve high-quality patient care Mutual respect, true sharing of power and control are essential Ideally, a dynamic, interactive process in which patients work together with healthcare providers to meet patients' health objectives

Resolving conflict requires

Increased cognitive, emotional, behavioral skills Confidence Competence

The Concept of Collaboration

Increased emphasis in nursing community on value of interprofessional collaboration and practice to improve patient outcomes Interprofessional: professionals from various disciplines along with support staff, patient, family members Successful collaboration requires that nurses -Develop skills in communication, teamwork -Value roles, responsibilities of other team members -Work to establish climate of mutual respect

In healthcare organizations, bullying linked to

Increased rates of employee absenteeism Increases in work-related injuries Decreased productivity Negative effect on patient safety, quality of care Incivility and disruptive behaviors violate ANA Code of Ethics for Nurses Provision 6 addresses nurse's responsibility to create culture of excellence Core Competencies for Interprofessional Collaborative Practice Values/ethics competency stipulates that healthcare team members must place interests of patients, populations at center of care

Workplace bullying: long-term behavior (≥6 months)

Involves verbal attacks, refusal to assist others, speaking negatively or tauntingly Can escalate to physical threats

Coordination and consultation

Midrange levels of collaboration seeking to maximize efficiency of resources

Typical causes of conflict between individuals, among groups

Miscommunication Inaccurate information Mistrust Ambiguous role expectations Ineffective leadership Resistance to change

communication skills

Miscommunication is one of most frequent root causes of sentinel events True collaboration requires skilled communication, mutual respect Expert collaborators hold themselves, each other accountable Each member of healthcare team should be sensitive to differences in communication styles, effects of own style on collaboration Team-centered communication Includes appreciation for member contributions Focuses on the "we" versus one-sided commands Focuses on shared responsibilities Effective communication occurs only if each team member commits to understanding each member's specific role, appreciating member as individual For patients, communication is key component of effective nursing care

Co-management and referral

Upper levels of collaboration Providers responsible for own aspects of care, direct patients to other providers when problem beyond initial provider's expertise

Mutual respect and trust

Mutual respect--When two or more individuals show, feel honor or esteem toward one another trust--When an individual is confident in actions of another individual •Mutual respect and trust imply shared process and outcome •Must be expressed both verbally, nonverbally -Important not to verbalize respect or trust while demonstrating lack of them through actions •Past attitudes may impede efforts toward collaborative practice •Magnet hospitals: example of successful efforts by healthcare organizations to foster respect among professionals

covert conflict

Not discussed openly May be avoided or ignored May be exhibited in reactive, repressive, and avoidance behaviors Avoidance may be appropriate when emotions flaring, individuals(s) would benefit from time to regain composure Sustained tactics of covert conflict → increased stress, distress, confusion Acknowledgment of covert conflict not easy Everyone involved will have different perceptions of the conflict

Collaborative Members of Healthcare Team

Nurse Unlicensed assistive personnel Complementary healthcare provider Case manager Dentist Dietitian or nutritionist Information technology expert Occupational therapist Paramedical technologist Pharmacist Physical therapist Physician Advanced Practice Registered Nurse Physician assistant Respiratory therapist Social worker

Information exchange

Planned communication but unilateral decision making, little collegiality

American Nurses Association (ANA) Standards of Professional Nursing Practice

Recognize collaboration as key component of nursing practice Standard 10: specific competencies related to nurse's role in collaboration

Interprofessional teams

Recognize each individual profession's value, contribution Atmosphere of mutual trust and respect Open discussion, shared decision making

in healthcare environment, two primary sources of conflict

Role boundary issues Lack of understanding of value of all team members Which tasks each team member is authorized to perform Accountability Particularly when team members did not hold selves accountable

The Nurse - Physician - Provider Relationship

Should be strongest collaboration that nurses have to meet patients' needs Both nurses and physicians can contribute to inadequacies in this relationship Lack of confidence on part of nurse Attempt to save face Fear or repercussions Deference to physician Attempt to preserve patriarchal nurse-physician relationship Conflict can be barrier to effective client care Cooperation, collaboration integral to success of this relationship

Interprofessional Settings

Skilled nursing, rehabilitation, long-term care facilities Schools, educational settings Assertive community treatment Mental health and support services in community for individuals with serious mental illnesses Elder care centers and services

Nurses may also be involved in collaboration

To develop community initiatives To write or revise legislation To conduct health-related research Nurses must assume accountability, increased authority in practice areas

Verbal abuse: malicious, repeated, harmful mistreatment of an individual with whom one works

Whether individual is equal, superior, or subordinate In healthcare setting, may occur Between patients and staff Between nurses and other nurses Between physicians and nurses In all other staff relationships

Goal of collaboration in healthcare environment

improve patient outcomes

Conflict competence

purposeful development of these skills

Collaboration

two or more people working toward a common goal by combining skills, knowledge, and resources while avoiding duplication of effort

Responding to Conflict

•How individuals respond to conflict varies -Responses may vary in different circumstances •Interactions, accompanying behavior may be unpredictable -Response to such behaviors can trigger unreasonable or inappropriate retort •Typical responses -Avoidance -Minimizing -Prematurely "fixing" problem but not root cause •Such responses can set up barriers, prevent successful problem solving

•Nurses have obligation to report bullying

•Nurses should recognize workplace bullying, be aware of its effects, follow organizational policies and procedures for reporting •Reports of bullying should include -Date, time of events -Description of events -Identification of any witnesses •Individuals in leadership positions should address issue to stop bullying •Nurse should be aware of organizations that may be available for assistance -State nursing association -American Nurses Association Department of Justice

Interprofessional Collaborative Practice

•Objectives -Provide patient-directed, patient-centered care using interprofessional, integrated, participative framework -Enhance continuity of care across continuum of health -Improve patient and family satisfaction -Provide high-quality, cost-effective, evidence-based care that improves patient outcomes -Promote mutual respect, communication, understanding between patient and members of healthcare team -Provide opportunities to address and resolve system-related issues, problems -Develop interdependent relationships, understanding among providers and patients

Incivility in the Workplace

•Problem believed to be more widespread than reports indicate -Individuals might not report problems ▪Fear of retribution ▪Lack of knowledge of reporting system ▪Assumption that the behavior is acceptable ▪Failure of administration to support or respond to previous reports ▪Overall lack of awareness in individual or staff •Conflicts involving staff -Hostile behavior by one person increases anxiety of others -First response should be to communicate control, calm situation -Situation more complex when nurse manager or team leader is hostile ▪Requires assistance from higher-level management -Open conflict should not occur in patient or public areas

Managing Conflict Within the Healthcare Team?

•When effectively managed, conflict can bring up issues that need to be addressed -Can result in beneficial outcomes for individuals, groups, organizations •If nurses take positions of avoidance, compromise, or accommodation, can lead to resentment, ambivalence about their job •Anticipating that conflict will occur, being prepared to deal with and manage it constructively is leadership skill, essential to professional growth •Although viewed as negative, conflict can be impetus for better communication, stronger team relationships, healthy changes •Successfully addressing conflict requires self-awareness -Self-inventory tools -Personal inventories

Horizontal violence (HV)

•aggressive acts committed against a nurse by one or more nursing colleagues -Behaviors may include ▪Gossiping about, speaking sarcastically to target nurse ▪Unkind or antagonistic interactions ▪Divisive behavior ▪Condescending or patronizing behavior

-Status-based

▪Based on hierarchy (e.g., physician "giving orders") ▪Focuses on needs/desires of more powerful team member ▪Forceful language that conveys or reaffirms status ▪Does not lend itself to dialogue

-Team-centered

▪Emphasizes shared problem solving ▪Uses "we" statements ▪Shared responsibility, open discussions