Int Arch Nurs Health Care ISSN: 2469-5823

• Abstract
• Introduction
• The Need for Health Care Teams
• Roles Performed in Health Care Teams
• Challenges to Working in Health Care Teams
• Communication and Conflict in Health Care Teams
• Interpersonal Dimensions of Health Care Teams
• Conclusion
• References

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International Archives of Nursing and Health Care

Center for Health and Risk Communication, George Mason University, Fairfax, USA

Abstract

It is increasingly important for health care professionals and consumers to participate actively and competently in interprofessional health care teams to contribute specialized knowledge and skills toward addressing complex health care challenges. However, team members must be sensitized to the communication demands of working effectively in health care teams. Team members should be able to use strategic communication to provide important input on making complex health care decisions, contribute to the delivery of team-based care, and enhance health outcomes. Each participant in the health care team should bring specialized knowledge, information, and skills to the health care enterprise that can facilitate effective delivery of care and improve health outcomes. Health communication strategies need to be developed within health care teams to promote cooperation between team members, to share relevant information, and to promote coordination in making relevant health decisions. This article examines the need for teamwork in health care, the challenges to working effectively in teams, and the communication strategies and skills needed to promote teamwork in effective health care teams.

Introduction

There are numerous complexities to working effectively in health care teams. The challenges to interprofessional coordination are often underestimated and such coordination demands advanced interpersonal and group communication skills, as well as sensitivity to professional and cultural differences. There is limited training for interprofessional teamwork in most health professional educational programs, with each professional group learning in isolation from other groups and health care consumers are rarely well prepared to participate actively in health care teams [1]. However, once health care professionals and consumers confront complex health care issues, they are expected to be able to work together collaboratively. This commentary article focuses on enhancing understanding how strategic communication can influence group climate, conflict management, and group decision-making in interprofessional health teams to promote effective team performance. The article is grounded in the Relational Health Communication Competence and Health Outcomes Model that describes the need for collaborative interprofessional health care practices to enhance health outcomes [2,3].

The Need for Health Care Teams

The modern health care system has become exceedingly complex and specialized with a range of different health care professionals working together to help consumers address their health problems. Often the most serious health threats, such as invasive cancers, heart disease, and HIV/AIDS demand close coordination from a variety of different health care specialists (such as nurses, pharmacists, therapists, social workers, surgeons, oncologists, cardiologists, anesthesiologists, and internal medicine physicians) [4-7]. Moreover, the patient and the patient's personal health care support system (including key family members, advocates, friends, and others) also need to participate actively in making important decisions related to delivery of care, long-term treatment, and rehabilitation [8]. These interdependent health care professionals and health care consumers often need to work together in interprofessional health care teams to coordinate their efforts and to share relevant information needed to provide the best health care services [9].

It is not easy to coordinate the different efforts of all the unique individuals who comprise interprofessional health care teams, even though the team members depend upon one another to provide appropriate health care services to achieve the best health outcomes [10,11]. Unfortunately, coordination and cooperation in health care does not happen automatically. In fact, there are often tremendous problems with promoting coordination of care in modern health care systems [12]. It takes a lot of work to get everyone participating in an interprofessional health care team to work together effectively [10].

Team members need to learn how to work together cooperatively, how to communicate with one another meaningfully, and how to make good health care decisions together [10-15]. It is critically important for team members to share relevant information they possess concerning the health care situation with all of the different members of their team, including health care providers, administrators, and consumers who are involved in health care situation, so they are all on the same page and know what is going on with the patient and the patient's treatment plan. Each member of the team is likely to have specialized knowledge and experiences relevant to the health care situation that can help the team make informed health care decisions. However, the best ways to share this specialized knowledge and information may be difficult for team members to accomplish.

Even when team members are able to share their specialized knowledge effectively and all the involved team members have been provided with the latest relevant health information, it does not guarantee that the team members will cooperate with each other in the delivery of care. Each team member will inevitably have his or her own personal interpretations about the health information provided, and each is likely to make different decisions about priorities for care and the best courses of action based on each person's unique background, expertise, and involvement in the case [13]. For example, a pharmacist is likely to focus on the benefits and risks concerning medications that may be relevant to the case [14]. A surgeon is likely to have a different perspective on the case, likely focusing on the different surgical interventions that may be warranted. Certainly, the patient will have a unique perspective about treatment decisions related to his or her concerns about the complexity of different treatments, the potential the treatments will help address the health problem, as well as concerns about implications of different course of treatment for pain, suffering, the length of hospitalization, rehabilitation, and costs. All of these different orientations to the same health care case are legitimate and important perspectives to consider in making the best health care decisions. Team members can share their different insights and expertise to help address complex health care problems. That is why it is important to work in health care teams.

Sharing relevant information and expertise is a necessary part of developing effective health care teams, but it is not enough to enable health care teams to work well. Team members need to not only share information with each other, they also have to be able to act on the information shared together to make good informed health care decisions. This means that each team member has to be responsive to hearing the perspectives of other team members, each team member must be willing to be influenced by the information shared by other team members, and the team members much be able to make collaborative decisions together that reflect the specialized information and insights shared within the team [15]. Strategic communication is needed to enable team members to work together to make informed, collaborative, and responsive health care decisions and this module will explore the conceptual issues involved in strategic health care team communication [16].

Roles Performed in Health Care Teams

There are a variety of important behavioral roles performed by different members of interprofessional health care teams. Communication is the process through with team roles are expressed and team goals are achieved. Two primary team roles are leadership and follower roles. Leaders are team members who exert influence over team activities by providing other team members with guidance to accomplish specific group goals. Leaders often assign projects and provide task instructions to other team members. For example, a health care team leader might ask other members to review specific laboratory results to determine how well patients are responding to treatments. The leader might provide them with a form to fill out that guides their review of these lab tests and can be shared with other group members when they meet to make treatment recommendations for the patients. Leaders depend upon members of the team to follow the directions provided to them (followers), enabling leaders to influence group process.

Typical team leadership activities include calling for and conducting team meetings to share information and make decisions, establishing standards for group interactions, raising topics for team deliberations, assigning responsibilities among team members, inviting members to share their individual perspectives on different issues under discussion, introducing new and relevant information to the group, initiating team decision making, and introducing strategies for implementing group decisions. Leaders are often appointed and assigned to official leadership roles. These are formal leaders of health care teams. Frequently the formal leaders of health care teams are senior physicians or the primary provider in-charge of the health care case that the team is addressing. Sometimes health care teams are also led by senior health care administrators who are appointed as formal leaders. However, there are times when different team members also assume informal leadership roles (sometimes referred to as emergent leaders) based upon their relevant expertise and experiences concerning specific issues the team is addressing [17]. These informal leaders help address team issues by leading discussions and decision making activities on topics on which they are especially knowledgeable. For example, when discussing the best medication regimen for a patient the formal team leader might ask a pharmacist who is a member of the team to lead the discussion and guide medication selection decision-making [18,19]. In another situation, the formal leader might ask a nurse who has been caring for a specific patient to lead discussion about the ways the patient has been responding to treatment [20]. Both formal and emergent leaders need to be skilled communicators to facilitate group discussions, information sharing, conflict management, decision making, and implementation of team decisions.

Prominent management theorist Kenneth Benne and Paul Sheets [21] described functional and dysfunctional roles that are often performed in groups by leaders and followers. Functional roles help the group achieve goals, while the dysfunctional goals can distract the team from achieving their goals. Task roles are functional roles that help facilitate accomplishment of team activities and responsibilities. These role activities include contributing ideas, seeking relevant information, and providing feedback to other members to help manage team goal accomplishment. Maintenance rolesare another type of functional role that helps to establish and preserve good interpersonal relations and cooperation among team members. Maintenance role communication activities include expressing support and encouragement, making comments to reduce tension, and encouraging cooperation. Dysfunctional roles, however, can limit team progress, and should be minimized to improve group process because they include overly aggressive and blocking behaviors, such as hostile comments or refusing to respond to others' requests, that reduce team effectiveness. Effective interprofessional health care team leaders balance task and maintenance roles, while minimizing the expression of dysfunctional roles. They try to give all team members an opportunity to communicate, so team interactions are not dominated by one or a few team members. It is important to maintain confidentiality of sensitive and private health issues discussed by the team. It is also important for team members to be receptive to the ideas of other team members and to treat each other with respect. Failure to follow these expectations can cause serious impediments to accomplishing group goals.

Challenges to Working in Health Care Teams

There are many challenges to working on health care teams. One of the major challenges is finding the time for busy team members to meet and share information. Scheduling of meetings needs to be responsive to team members' schedules and it is often best to have a standing weekly or bi-weekly meeting schedule that team members can place on their agendas. Meeting remotely via conference call, Skype, or video conferencing can often make it easier to accommodate team member schedules and travel demands. There are also time demands in preparing for team meetings, reviewing relevant background materials (patient charts, lab results, medication information, research findings, etc.) so team members can stay abreast of the issues under consideration and participate meaningfully in team deliberations. It is important for each team member to be committed to actively preparing and participating in team activities.

Another major challenge to working effectively on health care teams is learning how to interact effectively with other health care professionals and health care consumers. Team members typically come from very different professional backgrounds, and sometimes have other differences based upon education, age, gender, and cultural background, that can make team interactions complicated. Different health care professionals bring unique perspectives, strategies, and language to examining health care situations. For example, pharmacists, social workers, surgeons, and nurses are likely to perceive health care situations from their own unique professional backgrounds [22,23]. It is important for these different team members to explain their perspectives in language and with examples that other team members can understand. It is also important for different team member to be receptive to considering the different points of view that are likely to be expressed by different team members. Even among different branches of medicine (internal medicine, psychiatry, oncology, cardiology, surgery, etc.) there are likely to be very different perspectives to addressing health care issues that need to be examined by the team in determining the best courses of action for addressing health issues.

Health care providers and consumers are likely to have very different perspectives on health care issues, complicating team communication [8]. Consumers are likely to have very personal issues about the implications of different treatment, such as will the treatments be painful, debilitating, or expensive, that will guide their evaluation of different treatment options [9]. While providers might focus on more instrumental treatment issues, such as the expertise needed for administering different treatments, the availability of needed equipment, and/or scheduling issues for delivering the treatments. These different consumer and provider perspectives are all important and need to be considered in making the best team decisions. That is why it is so important for the different members of the health care team (including consumers) to share their ideas and concerns with the group. Consumer participation on health care teams is crucially important to ensure that the wishes and concerns of patients are taken into account when making team decisions [9]. Sometimes the actual patient may not be able to participate actively in health care teams due to their conditions. In these cases, it is important to include patient advocates, such as family caregivers, in health care teams to make sure the patient's point of view is included in team deliberations.

In addition, health care team members often have to consult with support staff (this includes clerical, technology, administrative, housekeeping, food services, security, and other staff members) to effectively deliberate and make good decisions about complex health issues. Support staff members often possess specialized operational information about patients and health issues. They can contribute important insights into the history and background about the issues the team is examining, how things are accomplished within health care delivery systems, and what resources and strategies are available to address health issues. Health care teams sometime need to enlist the help of key support staff in implementing team decisions. For example, if a decision is made by the health care team to deliver specialized health information about medical procedures to patients via television to address patient concerns about these treatments, they probably will have to work with hospital administrative and technology staff members to find out how to accomplish and implement this decision. Consulting with support staff can increase the effectiveness of teams by framing team decisions in the real operational constraints of the health care system and ensuring that decisions can be translated into actual health care system practices [24].

There are a number of challenges to effective interprofessional communication among team members [25]. Differences between team members due to distinct health care professional backgrounds, with different training, unique expertise, lead to different approaches to addressing health issues. These differences can be understood as unique professional cultures and team communication can be seen as a form of intercultural communication [26,27]. Cultural groups, including professional cultures, socialize members through ongoing communication and reinforcement to see the world through the lens of established cultural norms (rules about how things work and how members of the culture should behave) [26]. The professional training that different health care providers have experienced orients them to different key aspects of health care. For example, nurses are educated to focus on delivering care to patients, physicians are educated to focus on diagnosing and treating health problems, and pharmacists are educated to focus on the medications and related therapies needed to address health issues [28]. These are different, but complementary parts of health care delivery that are all relevant to health care team deliberations. However, sometimes cultural groups do such a good job socializing their members to accept cultural norms, they tend to think their areas of focus are most important and valid, discounting the importance, or even the validity, of other professional approaches. This tendency for health care providers to over-value their own cultural perspective in comparison to other professional cultural approaches is known as ethnocentrism and can be a major barrier to interprofessional communication in health care teams.

It is important for team leaders to develop strategies for overcoming ethnocentrism that stems from intercultural and interprofessional differences. To do this, the leader must establish a team norm for interprofessional respect and receptivity. The leader can express interest in hearing different professional points of view and encourage the expression of different professional perspectives during group deliberations. Team members can also show appreciation for learning about different relevant approaches to addressing health issues and describe how the unique perspectives helped lead to responsive team decisions. In essence, the best health care teams demonstrate interprofessional cultural sensitivity and cooperation [26].

Team members must be ready and able to share relevant information with other team members to accomplish team goals. Relevant health information is one of the most important resources available to health care providers and consumers in making their best health decisions [9]. Timely, accurate, and appropriate health information enables team members to carefully consider the different aspects of health issues and to make informed health decisions about how to best respond to these issues. Often, pertinent information is not easy to access in complex health care situations. It is the job of health care team members to seek relevant information, share it with team members, and use the shared information to analyze the health issues under deliberation. Sometimes team members have access to relevant information about a health issue due to their experiences with the issue. For example, nurses may have noticed changes in the ways that a patient has responded to treatments over time from direct bedside observations that other team members might not have access to. Pharmacists might have access to the history and range of medication prescriptions for a patient that other members of the team might not have access to. Moreover, the pharmacist might have access to specialized information that could help identify any potentially dangerous interaction effects across these prescribed drugs. So, team members can share relevant information based upon their unique experiences with the case under examination by the team, as well as from their specialized knowledge about health issues.

It is important for team members to provide usable health information that can lead to important team decisions about addressing health issues. It is not enough just to share general information about a medication or therapeutic procedure. The team members must be able to apply relevant health information to the specific health cases under investigation by the team. How can we use this information to address this issue? What does the information suggest about best treatment strategies, potential risks, and/or opportunities for implementing health decisions? For example, in a case where team members are exploring next steps for therapeutic steps for addressing a serious health problem a patient is being treated for when the current treatments that are being used are not helping the patient, team members can help achieve team goals by suggesting specific evidence-based treatment options that can be implemented to improve the care for this patient. The treatments recommended can be based upon team members' personal expertise, their knowledge about new treatments that are available, or even about clinical trials (research about new treatments) that the patient may be eligible for. Finding and sharing relevant information is a primary goal of the interprofessional health care team! Team members must not only be ready to gather relevant information, but they must learn how to carefully encode their messages so that others can understand their points of view. Encoding is the process of strategically planning the messages we send to achieve our communication goals. Team members need to present their health information clearly, succinctly, and persuasively to other team members so the team members can determine how to best use the information to address the health issues under examination [29].

In addition to information provision, it is imperative for team members to be good listeners so they can evaluate the information other team members hare with them. Listening effectively is not as easy as it may seem, especially when complicated health information is being shared in interprofessional health care teams [30]. Listening is more than just hearing what others have to say. It involves paying close attention to other team members' perspectives, considering their points of view carefully, and examining how the information being provided can be used to address the health issues under examination by the team. This process of careful, receptive, and analytical listening is often referred to asactive listening. Listening is not just a passive process of decoding the messages, interpreting the meaning of messages based upon past experiences, knowledge, and logic, but it also involves letting other team members know that you have heard and understand them [29]. Effective group communicators provide feedback to others to demonstrate understanding and empathy in health teams. For example, when a patient member of the health care team explains his or her concerns about different available treatment options, it is imperative for other team members to clearly acknowledge the patient's perspective and demonstrate that they are taking the concerns expressed seriously in suggesting treatment decisions. This is important for demonstrating respect and empathy (genuine understanding) for the strongly held perspectives of other team members. As we will discuss in a later section on relationship development in health care teams, the expression of empathy is a critical factor in building relationally strong and cooperative interprofessional health care teams.

Communication and Conflict in Health Care Teams

One of the major challenges to leading health care teams is managing team conflict, arguing about the merits of different ideas. Conflict is an essential part of health care team process for enabling teams to make good decisions [26]. There may be a tendency in groups to muffle conflict because arguing can be uncomfortable in groups and may make team members feel uneasy. Sometimes team members just go along with what they think may be the will of others in the group, rather than arguing for their own ideas. This often leads to bad decisions, something referred to as groupthink [29,31]. Encouraging team members to express different conflicting ideas is the best way to avoid groupthink and enable the team to explore a variety of perspectives on a complex health issue.

Conflict encourages the expression of different ideas and courses of action for the team to consider, enabling exploration of different options and preventing premature decisions that don't take into consideration other important perspectives (groupthink) [31]. Conflict is also an exciting form of communication that encourages involvement and attention among team members. While conflict is exciting, it can also be exhausting for team members, which encourages them to search for potential solutions to expressed conflict, including the development of useful creative compromises for helping to address complex health issues [29].

Yet, conflict can be dangerous if not managed effectively in health care teams. Often, those who are not skilled at ethical conflict strategies, may engage in angry, hostile, and even violent behaviors that can diminish team process. One of the primary ethical conflict strategies is to focus on ideational conflict versus personal conflict. Ideational conflict examines different competing ideas, perspectives, and points of view, while personal conflict focuses on individual personalities and character attacks [29]. Personal conflict needs to be avoided in health care teams because it alienates team members, hurts feelings, and undermines cooperative interpersonal relationships. Skilled team leaders encourage team members to explore different perspectives without criticizing others for having different points of view. This means keeping an open mind towards the merits of ideas that are different from your own and looking for opportunities to compromise between different ideas expressed in health care teams.

Interpersonal Dimensions of Health Care Teams

Perhaps the most basic communication process in building effective interprofessional health care teams is the development of effective interprofessional relationships [32]. Relationships are the agreements we establish with others to interact in certain ways to help us accomplish our goals [29]. For example, we may establish a good relationship with our personal physician to honestly share health information, pay attention to each other's needs, and demonstrate respect and concern for one another. This helps to accomplish both the task and maintenance needs for receiving good health care. We need our doctor to listen to our health concerns, provide us with relevant health information, provide the help that we need to maintain our health, and also to help us cope with any fears and anxieties we have related to our health conditions. Physicians depend on establishing good relationships with their patients to encourage their patients to share relevant information about their symptoms and health histories to guide diagnoses, to carefully listen and follow the health care recommendations they offer, and to treat them with respect. In health care teams we also have both task and maintenance needs for working with other team members. Task needs involve the use of relationships to accomplish specific tasks, such as information gathering and decision making in health care teams. Maintenance needs involve establishing comfortable and harmonious interactions with one another, such as expressing respect, comradery, and cooperation in health care teams. By developing good relationships among team members we encourage them to share information with us, listen carefully to what we have to say, and to treat us professionally. We use good relationships to establish rapport, trust, and collaboration in teams. When there are poor relationships between team members it is very difficult to achieve team goals because team members are not encouraged to cooperate with one another, to share relevant information, or even to treat one another with respect.

Every time we communicate with someone else our interaction has an effect on our relationship with that person. Typically, the interaction either helps us build a stronger more cooperative relationship (this is referred to as relational development), or it diminishes the relationship (this is referred to as relational deterioration). Therefore, it is important for team members to learn how to use their team communication to build effective team relationships. Once relationships are established we need to monitor the ways we communicate with one another to keep our relationship moving in a positive direction. This is referred to as relational maintenance. This means that the ways we communicate in health care teams is very important to building and maintaining effective team relationships.

Self-disclosure is an important part of establishing effective relationships. Self-disclosure involves telling others about ourselves, our ideas, and our goals. Yet, self-disclosure can be risky, because we give up some of our personal privacy every time we disclose information about ourselves. Self-disclosure works best for building relationships when it is mutual and reciprocal. Mutual and reciprocal self-disclosure occurs when both parties who are building a relationship share similar kinds of information with one another about themselves. Often we begin by disclosing relatively basic and not very revealing information about ourselves, such as our names, our professions, and where we work. Over time we can build up to sharing more personal information about where we live, who we live with, and what we do in our spare time. When we share personal information incrementally and mutually over time, it is less risky to get to know one another because we are not opening our privacy barriers alone, but are doing this together.

In health care teams it is important to encourage team members to share personal information so they can get to know one another, learn about each other's backgrounds (especially their areas of expertise), and to become aware of the unique perspectives on different health issues team members possess. As team members learn more about each other through mutual self-disclosure they also begin to feel more connected with one another, and they learn how to communicate effectively with each other in health care teams. They learn how other team members like to be addressed, how formally they like to communicate, and what topics and issues are most important to them. They also learn about the kinds of language they use and the relevant areas of expertise they possess.

Perhaps the most important part of building and maintaining effective relationships is the use of interpersonal communication to learn about and meet mutual relational expectations, a process that has been described as the building of implicit contracts [29]. Implicit contracts are mutual agreements we make with one another, that are often unspoken, about meeting relational expectations about how we want to be treated. These communication expectations include how we address one another, the kinds of topics we discuss, the language we use, how we include one another, the ways we share power and control, as well as the ways we express emotion and concern for one another. We typically learn about others expectations for our communication with them by observing their responses to us. If they respond positively to the way we communicate, we make a mental note to use the same communication strategies with them in the future. If they respond negatively to something we say and do, we decide not to use these communication strategies with them I the future. It is more comfortable for people to communicate and enforce relational expectations subtly, but if someone we interact with continues to violate our communication expectations the reaction can become more overt. For example, if a health care team member does not pick up on the fact you don't want to be addressed by your last name and keeps addressing you that way, you might eventually say to them with some consternation, "please don't call me that anymore; I want to be called by my first name." However, by the time you get to this overt level of response (a form of metacommunication, or communication about the ways we communicate), you are likely to be pretty frustrated with this dense team member and probably have not established a very satisfying relationship with them.

The more we are able to meet the relational expectations of others, the more comfortable they will feel with us, and the more they will want to meet our relational expectations for them. This urge to match others' behaviors toward us is known as the norm of reciprocity, and it can encourage us to respond favorably to those who meet our relational expectations, as well as respond negatively to those who violate our relational expectations. The implication from the norm of reciprocity is that to develop strong cooperative interpersonal relationships in health care teams we need to be sensitive to identifying the expectations other team members have for us and meeting those expectations by the ways that we interact with them. The more we fulfill others' relational expectations for the ways we communicate with them, the more they are likely to strive to meet our relational expectations, establishing strong reciprocal implicit contracts that building cooperative relationships. On the other hand, the more we violate others relational expectations, the more they are likely to violate our expectations for them, weakening implicit contracts and diminishing relational cooperation.

To further complicate the relational development process, however, we need to recognize that the expectations that others have for us are likely to change over time as they evolve, as you grow, and as the situations we share together evolve. For example, as we get to know each other better, we might expect to engage in more friendly and personal communication with one another. Team members may expect those who they have worked with over time to back them up on different positions they advocate for. They may expect other team members to fill them in on important privy information they may have. They may expect others to do them favors in exchange for favors they can provide, quid pro quo. If a team member fails to recognize and fulfill these updated expectations, they are likely to disappoint relational partners and reduce the effectiveness of their relationships with these partners. This suggests that to build and maintain effective interpersonal relationships in health care teams, team members need to continually renegotiate and fulfill new implicit contracts. Failure to update implicit contracts will inevitably lead to relational deterioration in health care teams. Team leaders can help minimize relational deterioration by promoting sensitivity and adaptiveness in encouraging team members to meet one-another's relational expectations.

Relational development and maintenance in health care teams is an ongoing evolutionary process that demands ongoing attention and adaptation. If team members are attentive to the changing life-cycle of interpersonal relations in health teams these teams are likely to develop the ability to become increasingly collaborative and effective at addressing complex health issues cooperatively. Groups that establish strong communication norms for cooperation and support eventually develop a culture of cooperation that is tremendously useful in building effective interprofessional health teams.

Conclusion

Interprofessional health care teams have become an integral part of the modern health care system. These teams enable interdependent health care providers and consumers to share needed expertise for making complex and important collaborative health care decisions. Effective teams also promote coordination among different specialists and key stakeholders in delivering the best possible care. However, effective communication is an essential part of effective health care teams and care must be taken to build meaningful, respectful, and cooperative relationships among team members. It is important for team members to perform important functional task and maintenance goals within their teams, while minimizing the expression of dysfunctional roles. Teams also demand effective leadership, both formal leadership and emergent leadership. Effective leaders encourage the sharing of relevant information and management of productive conflict. Ultimately, the members of the best teams use their interpersonal communication skills to develop cooperative relationships and collaborative teams.

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