The Role of Communication, Collaboration, and Teamwork
For a patient to have an optimal outcome, it requires the expertise and cooperation of many individuals. Effective communication, collaboration, and teamwork are critical elements to the welfare of our patients. For this discussion, consider the following:

Identify key factors that enhance communication.
Describe potential barriers to communication.
Explore how communication can impact a patient’s experience both positively and negatively.

Discuss the Joint Commission’s stance on communication and identify tools that can be used to promote patient safety. What have you seen in professional practice? If you have not had the opportunity to witness this, what communication strategies could be used to enhance patient safety?
Be sure to support your discussion with references to the literature as appropriate.
Reference Book: Essentials of the U. S. Health Care System 4th
Author: Leiyu Shi; Douglas A. SinghEdition: 4th, Fourth, 4e Year: 2015 
ISBN: 978-1-284-10055-6 (9781284100556)
Interdisciplinary Health Care Teams
Primary Care Practice models have been described in the literature by a number of authors in recent years. Early descriptions include a limited number of providers of health care and were an outgrowth of the movement to train and utilize “non-physician” health care providers in “expanded roles” in primary care. Three practice models commonly used in primary care were described. These models include only the physician and the “non-physician provider”, who was a physician assistant and/or a nurse practitioner.

The Parallel Model:  The non-physician provider provided care to stable patients, and the physician cared for the more medically complex patients.
The Sequential Model: The nurse practitioner or physician assistant performs an initial history and physical exam while the physician assumes responsibility for differential diagnosis and management. Alternatively, the physician may see patients initially to screen for complexity, with the less complex patients being assigned to the non-physician.
The Shared Model: Care is provided to patients by all providers on an alternating basis regardless of diagnosis and complexity.

The Collaborative Model:
The Collaborative Model is an extension of the concept of team practice and the leadership focus is modified. Patients choose their provider as desired, regardless of the complexity of their problems. All providers collaborate as needed to provide safe, high quality care yet each provider practices autonomously. (Arcangelo et al, 1996)
Collaboration is defined as a joint communication and decision-making process with the goal of satisfying the health care needs of a target population. The basis of collaboration is the belief that quality patient care is achieved by the contribution of all care providers. A true collaborative practice has no hierarchy. It is assumed that the contribution of each participant is based on knowledge or expertise brought to the practice rather than the traditional employer/employee relationship (Archangelo, et al; p106)
Components of the Collaborative Practice model:

A common group of patients
Common goals for patient outcome and a shared commitment to meeting these goals
Member functions are appropriate to an individual’s education and expertise
Team members understand each other’s role
A mechanism for communication
A mechanism for monitoring patient outcome

Values/Behaviors that facilitate the collaborative model include:

Trust among all parties establishes a quality working relationship that develops overtimes as the parties become more acquainted.
Knowledge is a necessary component for the development of trust. Knowledge and trust remove the need for supervision.
Shared responsibility suggests joint decision making for patient care outcomes and practice issues within the organization.
Mutual respect for the expertise of all members of the team is the norm. This respect is communicated to the patients.
Communication that is not hierarchic but rather two-way facilitating sharing of patient information and knowledge. Questioning of the approach to care of either partner cannot be delivered in a manner that is construed as criticism but as a method to enhance knowledge and improve patient care.
Cooperation and coordination promote the use of the skills of all team members, prevent duplication, and enhance productivity of the practice.

Optimism that this is the most effective method of delivery of quality care promotes success.
The Interdisciplinary Teamwork System described by Drinka (2000) provides further development of the concept of collaborative team practice. It utilizes several identified methods of team practice in a “fluid system” that changes to match the health care problem with the most appropriate practice method. In this teamwork system the universe of health care professionals and health care–related professionals and non-professionals is large. (These methods of team practice are described in IDT Table 2.5 at the end of this Module).
Drinka defines the Interdisciplinary Health Care Team (IHCT) as “a group of individuals with diverse training and backgrounds who work together as an identified unit or system. Team members consistently collaborate to solve patient problems that are too complex to be solved by one discipline or many disciplines in sequence. In order to provide care as efficiently as possible, an IHCT creates “formal” and “informal” structures that encourage collaborative problem solving. Team members determine the team’s mission and common goals: work interdependently to define and treat patient problems; and learn to accept and capitalize on disciplinary differences, differential power and overlapping roles. To accomplish these, they share leadership that is appropriate to the presenting problem and promote the use of differences for confrontation and collaboration.”
In this model Drinka explains that multiple methods of team practice should be part of the arsenal of the health care professional. The need for ongoing interdependence and collaboration are the triggers to determine which method of team practice is the correct way to address the particular problem encountered, whether it is related to patient care or to the operation of the health care system. For an Interdisciplinary Health Care Team to function well, it must have the capacity to adapt to changing and complex situations. (Drinka, 2000, p47). Two or more professionals may belong to a core interdisciplinary team and at the same time use additional methods of practice with individuals, teams or groups depending on the particular need or problem.
Methods of Interdisciplinary Health Care Practice: Six methods of team practice are outlined that can function as a system for providing efficient health care when understood and utilized appropriately
You may have the opportunity at some time to create or develop an interdisciplinary team in your primary care practice setting.
Building a strong interdisciplinary team requires careful planning, commitment and constant nurturing. This section is adapted from the Pew Health Professions Commission Model Curriculum and Resource Guide (1995). It describes the important components of team formation. The student is encouraged to read more information from this guide that offers several case examples.
Membership on a health care team should ideally be determined by the disciplines and skills that are required for the effective realization of the goals of the team. Some professionals may only be required on an occasional basis so it is often useful to consider a “core” or “nuclear” team consisting of members that regularly function together on a full-time basis. Additional “extended” or “consulting” individuals provide important skills and services on an intermittent basis.
In the early stages of development, the team members need to spend time planning the following: Goals, Tasks and Roles, Leadership and Decision-Making, Communication, Conflict Resolution. This might include considering members of the core and extended teams, specific role definition for each member and members’ role expectations, definition of issues that need to be addressed by the team as a whole, members’ information needs, mechanism for coordinating exchange of information, mechanism for evaluation outcomes and making adjustments to the team.
In other words, a team needs to know where it’s going, what it wants to do, who is going to do it, and how it will get done.
Goals: It is often helpful to begin with a broad mission statement to which all members can subscribe. From this statement, the team can then devise specific goals that have clear, realizable endpoints and objectives that provide a specific means of achieving this goal. Prioritizing these goals will further help to clarify the mission of the team and serves as a useful activity to develop team cohesiveness. The dimensions of the goals may be long-term or short term or may arise from professional needs, patient needs or team needs.
The goads initially described by the team are not necessarily fixed, and it is important to continually re-examine, redefine, and re-prioritize the goals of the team as required over time.
Tasks and Roles: In primary care there is often some overlap in the skills of the various providers. Several professionals, for example, have expertise in interacting with patients, forming care plans, and educating patients. Several primary care providers can diagnosis and treat illness. Thus, rather than attempting to define rigid boundaries of practice to segregate team members, it is more valuable to develop effective ways of sharing some responsibilities and tasks.  It is better to begin by differentiating tasks before negotiating roles in the process of defining functions of team members. This emphasis on tasks before roles tends to diminish issues of professional territoriality and ownership.
The central issue in role negotiation is whether traditional professional roles and skills are unique or merely distinctive. Because of the issue of overlapping skills, members must clearly define the role expectations for the team. Are expectations clearly defined? Do roles conflict or are they compatible? Can an individual meet all expectations?
The decisions of who does what can be guided by provider availability, level of training, or member preferences. As with the setting of goals, it is important to periodically review and revise member roles as necessary.
Pitfalls arising from lack of role clarification:

new members are confused regarding what is expected of them and what they can expect from others
increased conflicts between team members
crises arise when members assume that someone else was responsible for handling the situation
team decisions are not carried out effectively

Leadership and Decision-Making: There are several approaches to the leadership of an interdisciplinary collaborative team. Historically, physicians have had the role of team leader in health care settings due to various cultural, gender, and power factors. Still relevant today remains the issue of legal responsibility for patient care. An emerging pattern in many primary care teams, however, involves equal participation and responsibility on the part of team members with “shifting” leadership determined by the nature of the problem to be solved. Emphasis by the team on “health care” rather than the narrower focus of “medical care” broadens the roles and responsibilities on non-physician providers. A team must address the following questions in developing a mechanism for making decisions:

What needs to be decided?
Who should be involved in the process?
What decision-making process should be used?
Who will be responsible for carrying out the decision?
Who needs to be informed about the decision?

Communication: An effective, coordinated team must have an efficient mechanism for exchange of information. At the simplest level, this requires the time, space, and regular opportunity for members to meet.
An ideal system for communication would include:

a well-designed record system
a regularly scheduled forum for members to discuss patient management issues
a regular forum for discussion and evaluation of team      function and development, as well as related interpersonal issues
a mechanism for communicating with the external systems within which the team operates

Conflict Resolution: Given the mixture of skills and professional backgrounds, and the complexity of interdisciplinary collaboration, a diversity of views and differences of opinion are inevitable. It is important to recognize, however, that conflict is both necessary and desirable in order for the team to grow and thereby develop greater efficiency and effectiveness. Conflict encourages innovation and creative problem solving, while successful confrontation and resolution of differences engenders increased trust and understanding between team members. Signs of failure to deal effectively with conflict, in contrast, include low morale, withdrawal, lack of involvement, condescension, depression, anger, and provider “burn-out.”
Barriers to dealing effectively with conflict include:

an idealized sense of “togetherness” that inhibits feedback and confrontation over differences
a professional tradition of obedience to authority and corresponding unwillingness to disagree
“banding together” of members of the same  profession when there is disagreement between professions
misunderstanding of the roles, skills, and responsibilities of other team members

Members need to focus on the overall mission of the team and the care of the patient when dealing with conflicts in order to avoid making differences of opinion “personal.” Agree to ground rules before attempting to solve the conflict. It may be helpful to have a team facilitator who does not have a “stake” in the outcome.
Negotiation strategies to consider:

separate people from the problem (i.e. diffuse the emotional component of the conflict by showing respect, listening carefully, and giving all parties an opportunity to express their views
clarify the conflict/recognize the problem
involved parties need to agree to work toward a solution
deal with one problem at a time, beginning with the easier issues
brainstorm about possible solution
focus on common interests, not positions
use objective criteria when possible
invent new solutions where both parties gain
implement the plan
evaluate and review the problem-solving process after implementing the plan

Possible outcomes of team conflicts:

avoidance: conflicting  members avoid each other or conflicting issues are avoided in team  discussion; leads to stagnation
capitulation/domination: leaves “winners and losers”; divisive for team
compromise: each party gives up something important; may lead to divisiveness and avoidance since members may feel that they have lost out
collaborative problem-solving: each party states clear, observable terms; solutions are sought that maximize net gains for both parties; members feel positively about a solution that is to the greatest benefit of the team

Health Professionals that are exposed early in their training to working with interdisciplinary teams will have more chance for success in team building and team practice.

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