All for One
Health care teams pool their individual strengths and ideas to deliver top-notch patient care in an atmosphere of mutual respect and open communication

By Cathryn Domrose
December 23, 2003

At the Alegent Health Bergan Mercy Medical Center's Joint Replacement Center in Omaha, Neb., being part of a health care team means that at mealtimes, everyone helps set up a common dining area.

At the SMDC Health System emergency department in Duluth, Minn., it means nursing assistants and the health unit coordinators-formerly known as ward secretaries-are respected for their contribution as much as physicians, nurse practitioners and nurses are for theirs.

At Southeast Missouri Hospital, it means the nurses know one another's needs so well, they help each other without being asked.

"Unfortunately, in nursing these days, everybody's so busy a lot of times they can't help other people," said Hope Botwinski, MSN, RN, an ICU staff nurse at Southeast Missouri.

"Being a good team member means helping other people. It means knowing when they would appreciate help."

And, say those who study or train health care teams, it means knowing how to accept help from others on the team.

Common ground

Health care used to be about individual care by individual providers, usually a physician and a nurse. But in recent years, changing patient attitudes, scarce resources and specialization have forced an increasing number of health care workers to work in teams, drawing on each specialty's strengths and ideas, with the patient as both a focus of and a main player in the care.

A good team makes patient care look effortless and smooth. Everyone seems to know his or her role. All team members respect and trust their colleagues. Disagreements are worked out without becoming personal. Everyone works together toward a common goal-be it saving a life, getting a patient ready to leave the hospital or teaching someone to manage a chronic illness.

But such teamwork, say nurse educators and trainers, takes incredible commitment from team members, team coordinators, managers and patients themselves.

Successful teamwork, say those who have participated in it, means learning to see the world through the eyes of other disciplines, and at the same time showing others what your skills and knowledge bring to the team. It means learning to work through conflicts by keeping the goal of the team in mind. It means constant communication among team members.

More than anything else, it means showing each other respect, say those who work in interdisciplinary teams.

"Teamwork is the way health care is delivered these days, but we don't pay enough attention to what it means to work as a team," said Ruth Ann Tsukuda, MPH, RN, associate professor at the school of nursing and school of medicine at Oregon Health & Science University.

"We assume it to be an easy concept, but it's extremely difficult. To be an effective team, you have to work at it."

Although few education programs emphasize interdisciplinary teamwork, many health care workers see it as the wave of the future.

"If the goal is to deliver patient care, that should determine how the team functions," Tsukuda said. "What does the patient need and how do we deliver the care they need? If you think about it, everybody doing their own thing isn't going to work."

Interdisciplinary teamwork is already a mainstay in certain areas like hospice and elder care. More hospitals are looking at team models of caring for patients and involving the patients more intensely in their own care.

Cardiac care centers, orthopedic units, oncology units and well-mother-baby units are looking at increasing patient education and focusing team efforts-from physicians to housekeepers-on sending home educated patients who have the resources and education to care for themselves.

Emergency departments in some hospitals are creating teams that might consist of a physician or nurse practitioner, one or two nurses, a nursing assistant and support staff to work on a specific group of patients. Chronic illness centers are experimenting with team approaches to helping patients manage their disease.

"Forty years ago, there was the nurse and the doctor," said Mark Darby, RN, CEO of Darby Training Programs in Omaha, Neb. Darby creates training programs that teach nurses, among other things, how to work in teams. "The doctor did one thing and the nurse did everything else."

Now, a hospital patient might receive care from a variety of health care workers, including respiratory therapists, physical therapists, occupational therapists, physicians of various specialties, pharmacists and social workers, Darby said. "It's now the nurse, the doctor and everyone else."

But although the players in health care have changed, in many cases the system has not, Darby said. Modern patient care, with much of its origins in the military, still has hierarchical roots. When there's a problem, he said, the tendency is to "push it upstairs, to take it to the doctor and let him solve it. … We have to start moving away from that. We have to move toward people who are equals. We have to treat other people on the team as equals as well as expect to be treated as equals."

Satisfaction guaranteed

Lori Stubbs, RN, case manager at Alegent Health Bergan Mercy Medical Center Joint Replacement Center has spent three years creating a team of nurses, physical and occupational therapists, physicians, even a housekeeper. Her team works together to educate patients, get them successfully through hip or knee replacement surgeries, get them moving and send them home with full knowledge of how their recovery will proceed.

The center has the highest patient satisfaction scores in the hospital-higher than even the well-mother and baby center, traditionally the highest scorer in patient satisfaction.

Patients send cards and letters, talking about the excellent care they received from the team. They come back to visit and give encouragement to new patients. The center has won awards for its team care.

But creating the team was no easy process, Stubbs said. Initially many people resisted changing, expanding or, in some cases, giving up part of their old roles.

At first, she said, many staff members resisted the idea that everyone help set up the common room for a picnic-style lunch that included patients, their families and caregivers.

But when they saw her doing it, and when they realized how much the patients enjoyed these meals, nurses, therapists, secretaries and anyone else available began pitching in.

Now, Stubbs said, everyone sets up the room, helps transport patients down to lunch and helps clean up. There is no "low man on the totem pole" expected to do the work, she said.

"There are pretty strong personalities here and pretty strong ideas," she said of the center staff. "They all know their own roles, but they all work together, too."

At SMDC Emergency Department, staff members worked as a team long before "teamwork" became a buzzword in health management circles. Because of the nature of their work, they have no choice, said Linda Way, RN, director of emergency services and Life Flight at SMDC Health System. "We don't know from minute to minute what we're going to be encountering. Teamwork is a part of the culture of the unit and the success of the unit."

The unit is working to formalize and tighten its teams, she said. Eventually, teams will consist of a physician, two registered nurses, a nursing assistant and a health unit coordinator, who answers phones and processes orders. Social workers, chaplains and other support staff will continue to work with the teams, she said.

Teamwork means trusting others to do things you can't always do yourself, Way said. For instance, she said, nurses in the department often are torn between helping distressed family members and attending their patients at the bedside. When the chaplains come in, Way said, she sometimes worries that they feel awkward about getting in the way of the medical care. But nurses trust and rely upon them to take care of family members while nurses attend to the patients, she said.

The interdisciplinary team approach may not work as well in some outpatient settings, where patients are transient, billing may be confusing or clinics may not have the resources to include specialties like social workers or mental health specialists on their staffs. In these areas, say some health educators, a parallel approach may work better, with physicians or nurse practitioners referring to or calling in other specialties as they need them.

Carolyn Nowosielska, MSW, RN, a student in the family nurse practitioner program at Washington State University in Vancouver, said she loved working with students from other disciplines as part of a project she did for the Oregon Burdick Interdisciplinary Team Training (ORBITT) program, out of the Oregon Health & Science University.

She and fellow team members-a pharmacy student, a public health student and a nurse-midwife student-created a group-visit program for patients with chronic illness at a rural Oregon clinic.

But although she came to appreciate the expertise of people in other health fields and calls on them regularly in her job at a county health clinic, she doesn't think her clinic would have the resources to hire a team of health workers who would regularly meet and discuss patient care.

Kay Roberts, Ed.D., FNP, FAAN, professor at the school of nursing at the University of Louisville in Kentucky and project director of the Harambee Nursing Center, reported similar results from a study of interdisciplinary teams of nurse practitioner students, social work students and medical residents who worked with low-income patients with chronic illness in outpatient clinics.

The students enjoyed working together and learned a lot about each other's disciplines.

Many were sad when the project ended. Some residents said they wanted to hire the nurse practitioner students after they graduated, Roberts said. But the entire team saw few patients more than once. Most didn't return to the clinic for follow-up visits, and those who did were not able to return at a time when the entire team could meet with them together.

"If you don't have a patient, you don't have a team," Roberts said. Roberts has had great success with interdisciplinary teamwork with geriatric patients in nursing homes.

"I learned a lot about trying to do interdisciplinary practice in a primary care setting. You have to have the consistency of interaction," she said.

Learning the language

One of the most important aspects of teamwork is learning to communicate not just opinions and ideas, but the reasoning behind the thinking, Darby said. It is also important to learn at least some of the language of each other's fields, he said.

Concerned about patients who reported nausea after joint replacement surgery, Stubbs decided to persuade the anesthesiologists to become part of the joint replacement center team. She gathered data on the nausea complaints and presented them to the anesthesiology department. She also gained the support of the center's medical director on the need to address the problem. The anesthesiology department was surprised by the numbers and impressed by the support of the medical director.

"They said, 'We want to help,' " Stubbs said. They made changes in medications and now call every week to see how patients are doing and to find out when the next team meeting will be, she said.

When team members disagree, they should keep conflicts from becoming personal, Darby said, or using passive-aggressive behavior if they feel they have been slighted. He recalled how when he was a night shift nurse and he felt a physician had treated him badly, he made sure to find a reason to call the culprit at 3 a.m. That, he said, is not the way to solve problems.

At the same time, he said, nurses should not back down from giving clear, strong opinions on patient care. "A nursing judgment is a valid judgment, based on a valid knowledge base," he said.

Teamwork does not mean giving up autonomy, say those who have worked with interdisciplinary teams. Karen Newton, MPH, the director of the Louisville study, said students who seemed to feel the most confident in their own disciplines contributed the most to their teams.

A study of staff nurses in England showed that nurses who scored higher in teamwork also seemed to be more autonomous and more involved in decision-making."You really have to be even more grounded and mature in your profession to be the best team member," Newton said.

Because of their training in assessment, communication and time management, nurses often make the best team coordinators, Tsukuda said. They also should take the lead in situations where they may have the best idea what the patient needs, such as education or sufficient support at home.

Managers also must give the concept of teamwork more than lip service by supporting teams, making sure they have time and space to meet and giving them enough resources, say those who work with health care teams.

Nurses on teams should be open to learning from others as well as teaching them. Botwinski said she has learned from a physical therapist about how to tell whether patients can support their own weight. Nowosielska said she was amazed to discover how much patient education pharmacists did, and now calls them regularly.

In the Louisville study, medical residents and nurse practitioner students discovered that areas of overlap in their professions created a common ground for discussing patient issues, and came to appreciate the things they had in common as well as the things they did differently, Roberts said.

They also had to learn how to include the social work students, who sometimes felt left out when team conversations became too clinical.

Respecting and trusting fellow team members and getting them to respect and trust you is probably the most important aspect of teamwork, say those who work with or on teams.

"I don't think you can have a real team environment without respect," Way said. In her department, she said, nurses feel like the physicians listen to them, even if they don't always agree. "We like the doctors we work with, and the respect is there both ways. We're a tight group. You work together in these real intense, awful situations and you bond."

They bond when a child dies and they have to tell the family. They bond to work on a patient minutes from death. They bond on codes, when a physician asks if anyone else has any other ideas before stopping treatment.

"They're working hard together to save someone's life," Way said. "They couldn't do that job without everybody working together."

Contact Cathryn Domrose at kaguilar@well.com