Communication, Collaboration and Teamwork in Nursing

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This paper seeks to critically analyze, discuss and evaluate the benefits and challenges to effective communication, collaboration, and teamwork in an acute unit, using the case of a dementia inpatient, here called Emma (a pseudonym) in keeping with the Data Protection Act (2018). About 70% of inpatients are over 65 years and at least 30% of them have dementia, usually, with multiple co-morbidities, reduced motor functions, and declining cognitive reserves (George et al., 2013). These problems hurt their communication skills (Judd 2019; Regan et al. 2015). Additionally, these scholars sturdily express the importance of communication with dementia patients, regardless of their diminishing abilities.

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Given their multiple co-morbidities, there is no single profession that can meet all their needs. Hence, the importance of communication, collaboration, and teamwork among clinicians and other professionals.

Emma 77, who had multiple co-morbidities including impaired speech and leg ulcers, was an unpredictable service user with challenging behavior. She refused to take medication, removed wound dressings, picked and scratched on the wounds until they bled. As her wounds were not healing, her challenging behavior increased.

A Multidisciplinary Team (MDT) meeting, led by the Nurse, comprising Emma, Consultant Doctor, Tissue Viability Nurse (TVN), and Trainee Nurse Associate (TNA) was scheduled, in a quiet room. The TNA ensured that Emma was not hungry, her toilet and other personal needs were met. During the meeting, with a cup of tea and her needs met, Emma was calm in mood and showed interest to engage in conversation. The MDT sat down at Emma’s level and discussions were carried out conversationally, using both verbal and non-verbal forms of communication. The staff listened to Emma more than asking her questions while observing the non-verbal cues she presented. This environment enabled Emma to express herself, in body language, short sentences, and phrases.

The team deduced that Emma was in pain and the dressings seemed to cause itchiness. The meeting resolved to collect a wound sample and change the dressing type. Emma was detained under Section 3 of the Mental Health Act (2007) which gave the doctor authority to sign her for covert medication, He also prescribes a better pain management regime. The Nurse and TNA updated her care plan, risk assessment, and behavior chart. Both the resolution and documentation were carried out simultaneously. Within a few days after the meeting, Emma’s health and wellbeing improved. This scenario produced positive results based on good communication, collaboration, and teamwork.

At the core of effective and therapeutic person-centered nursing care, communication, collaboration and teamwork are fundamental (McCabe, 2006). In 1976, Miller and Nicholson illustrated communication using a simple linear model of Sender-message-receiver. This model, according to McCabe (2006) has a lot of assumptions that fail to consider intrinsic and extrinsic factors that can impede communication, such factors as values, culture, beliefs, physical environment, the medium used, etc. It places all responsibilities on the sender who is expected to be clear and accurate while it negates the need for open-mind and willingness of the receiver to participate (McCabe, 2006). Bateson’s Circular Transactional Model (1979) improves on the linear model by considering communication as an interpersonal process that takes place within a context. Based on such models, communication definitions are formulated. Three such definitions are by Hargie and Dickson, (2004); Hayes (1991); Ruesch, (1961). The vagueness, diversity, and broadness of these definitions show how dynamic and complex communication is. Ruesch’s, (1961) linear model definition, does not concur with the other two whose definitions subscribe to the idea, that this paper agrees with, that communication is an interpersonal process that effectively utilizes targeted skills and behaviors in interactions, to produce desired results (Hargie and Dickson, 2004; Hayes 1991). This was demonstrated in Emma’s scenario.

TNAs/Nurses should go the extra mile in communication with dementia patients. According to Grant (2018) and re-iterated by Nazarko (2018) Nurses/TNAs should translate, (give information and instructions), create trust, endeavor to know their patients by being friendly and sharing at a personal level, carry the right demeanor and be humorous while speaking clearly and using short, simple sentences. They should also maintain confidentiality, confidence, and competence (Nursing and Midwifery Council, 2018; Standards of Proficiency for Nursing Associates, 2018). Furthermore, patients are at the center of their care, therefore, to accomplish inclusive decision making and satisfaction, the European Union (2004); Health Department (2012) stresses the prominence of promoting patient-focussed communication, especially with the elderly who have dementia and learning disabilities, groups. For these groups, communication and relationships are fundamental to achieve professional standards, thus, person-centered care, non-verbal communication, and therapeutic interpersonal skills are integral (Nursing and Midwifery Council, 2018). These aspects of communication were demonstrated in Emma’s scenario when clinicians set the scene in a quiet and calm environment. The MDT chose the right time when the patient was most receptive to communication, i.e. Emma was not hungry and had her personal needs met. Meeting a dementia patient’s needs was highlighted as a positive aspect for effective communication by Fraizer et al. (2019); Mendes and Palmer (2018). Another positive quality for communication with dementia patients, according to Bryon et al. (2012), is to make communication more therapeutic by being conversational rather than asking questions, while listening and observing the patient’s reactions.

Emma’s scenario shows how collaboration among healthcare professionals can be used to yield cost-effective time management and simultaneous treatment for patients. It proves that every individual in health and social services has an important role to play in the provision of care and services (McNab, 2015). In a complementary way, Scaria (2016); Matziou et al. (2014); Grant (2015) assert that effective treatment calls for this multidisciplinary approach with clear and effective communication strategies and boundaries. Hale and McNab (2015) illustrate further that working together in a coordinated manner for the accomplishment of various treatments and interventions is critical. It helps to prevent errors, suboptimal patient outcomes, and fragmented care. This analysis proves, therefore, that interprofessional collaboration is an important and necessary element to uphold among health care providers.

Reeves et al. (2010) define collaboration as to how health and social care professionals work together to provide services or solve problems. This interactive professional relationship can be realised with mutually supportive cooperation, joint decision making, and constant communication, in which all the professionals involved are freely able to express their opinions (Ushiro & Nakayama 2010). These scholars emphasized the importance of effective communication in collaboration and teamwork. In the meeting with Emma, everyone took part to deal with the situation operating within the scope of their knowledge and working boundaries.

Teamwork can be defined in various ways. Deneckere et al. (2012) cited in Scaria (2016) defines teamwork as “a dynamic process involving two or more health professionals with complementary backgrounds and skills, sharing common health goals and exercising concerted physical and mental effort in assessing, planning or evaluating patient care.” The happy Manager website (2019) also gave a definition that highlights elements of cohesion and a positive working atmosphere. Considering the definitions above, the writer of this paper also appreciates an illustration given by Lancaster et al. (2015) using Malhotra’s (1981) Orchestra model exemplifying how health and social care professionals can work together like an orchestra, whose members hears and views music from different classic points yet, with their different types of knowledge and talents, they work together to produce a cohesive performance. Thus, in health care and social care provision, individual talents and perspectives of different professionals can be collaboratively blended to create high-quality enhanced patient-centered care. As demonstrated in Emma’s case, the patient is at the center of this consented effort to work together.

However, this ideal kind of teamwork is usually affected by gaps in and a lack of clear interprofessional communication (Liu et al. 2013; Thomassen et al. 2014). Underlying unresolved tensions and conflicts can contribute to poor professional communication in teamwork (Hart, 2011). To prevent a negative impact on the team’s morale and care delivery, conflicts should be resolved as soon as possible. Arnold & Boggs (2015); Harris et al. (2013) highlight that parties involved should identify causes, sources, and issues which underpin the conflict. They should, then articulate potential solutions while being assertive and respectful to the rights of individuals involved. Thus, interprofessional communication, collaboration, and teamwork can be complex, yet NMC (2018) requires Nurses/TNAs to work in partnerships with other professionals and agencies for the delivery of safe and effective care and better patient experiences.

Multidisciplinary teams can interact effectively at a macro level when they communicate using biomedical or psychiatric discourses which according to both Grant (2019); Smith (2016), use phrases unintelligible to most people. These discourses establish a professional identity as they are not just words, things, or phenomena but are systematic practices that form the object of which they describe (Foucault, 1969). For example, the 6Cs in nursing describe and set the limits of what something is, how the knowledge of what is known about it can be created and who has the right to discuss that phenomenon (Grant, 2019). TNAs should strive to learn, understand and be able to use the biomedical and/or psychiatric discourses as it helps them to belong and feel comfortable in collaboration with other professionals.

Professionals can improve on their communication in collaborative teamwork by being open, attending to their own emotions and wellbeing to prevent compassion fatigue and burnout (Zhang et al., 2014; Baughan & Smith, 2013). For example, one should always consciously reflect or acknowledge that they are tired and take time off. Biases, emotions, and prejudices are important elements that bring out the humanness of a person but if they are not managed well, they can hinder teamwork (Grant, 2019; Middleton et al., 2011).

Individual nurses/TNAs are expected to demonstrate high levels of personal self-awareness and wiliness to engage with other professionals even in the most difficult circumstances. Middleton et al. (2011) place emphasis on personal because one can only be professional when they reflect on their learning and understanding the purpose of exploring and appreciating new ways of working with patients/difficult service users, families, and other professionals. Another important factor to consider is the concept of unconditional positive regard, which can be achieved by accepting others as individuals who are entitled to respect and care (Carl Rogers, 1951 cited in Shefer, et al.2018).

MDT should communicate with dementia patients as individuals, understanding that each person has their own way of communicating. Research has shown links between ineffective staff communication and challenging behaviors, resulting in disruption of care, increased care cost, and stress for nurses/TNAs (Williams et al., 2009). Wang et al. (2015) further argued that despite the presence of aphasia, dementia patients’ vocal tones and behaviors are meaningful and may signal unmet needs. Failure by nurses/TNAs to appropriately respond to these needs may result in irritability, aggression, or withdrawal as was expressed by Emma before the meeting.

These professional relationships should be governed by a code of practice that embraces a sense of purpose, authenticity, empathy, confidentiality, active listening, mutuality, respect, dignity, and respect of the patient and each other (Grant, 2019; Middleton et al., 2011). Members should hold themselves mutually accountable to and for each other (Lencioni, 2017). Teams can use medical tools such as the SBAR which is an effective way to improve communication among staff while improving patient safety (Brewerd et al., 2011; Drach-Zahavy, 2015).

Communication, collaboration, and teamwork should be evident based (Nursing and Midwifery Council, 2018; Grant, 2010). These practices are considered safe and effective when they are supported by empirical knowledge and/or theoretical consensus by nurses and other academia, built over time (Grant, 2010).

The objective of applying effective interpersonal collaboration and teamwork within care provision has numerous problems. A growing body of evidence validates that poor communication among health care providers is harmful to patients and their families and is costly to health and social services (Price et al., 2014; Thomassen et al., 2014). While MacMillian (2012); Burford et al., (2013) believe that it is a power game that emanates from the historical role of physicians as primary leaders, decision-makers, and caregivers. These writers describe this observable negative fact as a dynamic hierarchy, where the normative structural hierarchy reinforces medical dominance that supersedes the pragmatic hierarchy that recognizes nurses/TNAs as experts in their clinical domain. Although this experience is slowly declining, as seen in Emma’s case where the Nurse took the lead, it is still being practiced. Rodriquez, 2015 on the other hand, believes the problem is the high volumes of rotating clinicians which disrupts communication continuity and flow of information. While Matziou et al. (2014; Price et al. (2014) cited disrespect, tone of voice, lack of patience, racial comments, negative criticism, and lack of response as other factors that affect the quality of communication collaboration, and teamwork. The writer believes that none of these factors is greater or lesser than the other. They are all negative and destructive to teamwork. Most of all they do not perpetuate positive patient outcomes.

In conclusion, supported by scholarly evidence, this essay has critically analyzed and delineated the importance of communication collaboration and teamwork with patients whose declining cognitive reserves reduce their ability to communicate and decode information effectively. It revealed how communication with dementia patients does not only encompass verbal and non-verbal cues but also involves the environment, the patient’s behavior, and personal needs.

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