Communication and Teamwork in Nursing

Communication and Teamwork in Nursing

The NMC Code (2018) sets out standards that Nurses are expected to adhere to in order to ensure and maintain safe professional working. Two important aspects highlighted in the code are Communication and Teamwork. Communication and Teamwork between staff and patients is essential in order to provide effective patient care and also in order to protect the best interests’ staff. This essay aims to discuss the important role that these play in nursing and the challenges that may face nurses. The essay will consider vital research that has been carried out into the benefits of effective communication and teamwork in nursing. Furthermore, it will acknowledge cases such as The Francis Inquiry (2013) and the Laming Inquiry (2003), in which poor communication or teamwork has resulted in adverse repercussions for the healthcare industry. In order to provide additional evidence, the essay will also reflect on recent placement experiences in order to provide further insight into the importance of communication and teamwork in all healthcare environments. 

According to The Code set out by the NMC (2018), all nurses must communicate clearly. In order to do so, the NMC (2018) stipulates that nurses must “use terms that people in your care, colleagues and the public can understand” (Page 9). The Code also states that nurses should “take reasonable steps to meet people’s language and communication needs, providing, wherever possible, assistance to those who need help to communicate their own or other people’s needs” (Page 9). In order to achieve this when dealing with patients it is essential that nurses ensure what they say is appropriate to the person’s age, language/culture and level of understanding (Royal College of Nursing, 2016).

When referring to good communication, there is a great deal more to consider than just spoken words (Royal College of Nursing, 2016). It is important to consider the tone of voice used, the message given out by body language, what the other person is saying, and to ensure accuracy of any written communication. There are five important aspects of communication; listening and attending, non-verbal, verbal, questioning and written (RCN, 2016). If nurses do not communicate well, care may be compromised. In order to communicate effectively, nurses must listen to what patients’ say, answer questions in ways that they can understand and process, and pass on information to colleagues. (RCN, 2016) It is vital that nurses are conscious of what they say to service users. Nurses must ensure that any communication is clear, accurate, honest and appropriate to the person’s ages, language/culture and level of understanding. It is also important to consider how things are said and the tone of voice. Nurses must ensure they are courteous and respectful when communicating with service users and colleagues alike. For example, ensuring that patients are addressed as they wish to be and avoiding the use of ‘pet’ names.

Communication is a key aspect of nursing which can provide benefits for patients. Good communication is vital for effective engagement with both patients and other healthcare professional and without it, care may be compromised. There is a potential for harm to occur from misunderstandings; by communicating effectively nurses are able to protect patients. This, in turn, helps to enhance the patient experience and reduce complaints. It can also have a positive effect on staff such as increased self-confidence, professional standing and reduced stress. The idea of effective communication is in the line with the NMC Code (2015), which states that nurses must “check people’s understanding from time to time to keep misunderstanding or mistakes to a minimum”.

In the majority of cases it is possible to protect patients from potential harm arising from misunderstandings by communicating effectively. (Ali, M 2017) While it is rare for serious harm to occur as a result of poor communication, there can be serious consequences for even minor failings. For example, wrong medication being administered as a result of errors in communication between colleagues. Another example of this is, during an end of shift handover, poor communication can lead to important information not being passed over, leading to possible patient harm. (World Health Organisation, 2007). Moreover, poor communication can lead to poor adherence to medication regimens, repeat visits to clinics, disputes and in some cases legal action. As a result, it is estimated that these failings cost the NHS over £1bn per year (McDonald, 2016). Furthermore, according to Jones (2010) patients are more likely to judge the quality of care they receive by the communication and human interaction with healthcare professionals’ than any other factor. Effective communication also increases patient’s confidence in healthcare professionals, making them more likely to follow any advice given. Despite this, according to an Inpatient survey carried out in 2016 by the Care Quality Commissions, almost one third of patients did not understand nurses’ explanations some or all of the time(CQC, 2017). 

There a numerous factors that can contribute to poor communication. Environmental factors such as background noise or busy environments can interfere with a patients’ ability to hear the message properly. It is also important to consider the patient’s condition, as messages may not be understood as a result, for example a patient with dementia or hearing problems. Practitioner factors can also play a part; if a nurse fails to communicate in way that patients can understand a message by be misconstrued. Additionally, language barriers can also cause problems with communication which may lead to errors being made. As previously highlighted, this issue is raised by the NMC (2015) and to avoid this nurses are expected to take steps to overcome such language barriers. According to the Royal College of Nurses (2016), such barriers can lead to misunderstandings, resentments, frustrations and demoralisation for both services users and staff. In order to avoid these communication barriers, it is vital that health care staff are aware and work together to develop solutions to overcome them. It was suggested by Egan (2010) that healthcare staff require additional training in order to better develop their communication skills.

A report about the Mid Staffordshire NHS trust by Francis (2013) raised concerns about communication. In his report Francis (2013) found “a failure of different teams within the hospital, as well as in the wider community, to communicate and share their concerns”. The report also highlighted a lack of respect between professionals and service users which proved to have a negative effect on communication. The NMC (2013) published a report in response to the Francis Report in which they declared that nurses “must use effective communication strategies and negotiation techniques to achieve best outcomes, respecting the dignity and human rights of all concerned.” As a result of the findings of the Francis Inquiry, NHS England developed the 6Cs, of which communication is a key aspect. According to the 6Cs “Communication is central to successful caring relationships and to effective team working. Listening is as important as what we say. It is essential for ‘No decision without me’. Communication is the key to a good workplace with benefits for those in our care and staff alike.” (NHS England, 2012) This further demonstrates the importance of communication in nursing.

During a recent placement at a North West nursing home, I experienced a number if barriers in communication due to the majority for the residents having advanced stage Dementia.  There are various forms of Dementia, all of which, over time diminish the person’s ability to communicate. When communicating with people with dementia, as much as 90% of their communication is nonverbal. (McNamara, G 2016) The person’s ability to communicate can vary with the stage of the disease and also from person to person. Taking this into consideration, it is vital that Nurses take a person centre approach when communicating with patients. In order to assist me in communicating effectively, I ensured that I liaised with staff at the Nursing Home who were familiar with the patients in order to understand their likes and dislikes. I found this to be extremely important to help adapt the communication accordingly with each patient. When dealing with non verbal patients, it was important to observe their behaviour and pay attention to my own non verbal communication such as body language and facial expressions. By observing non verbal communication it was often easy to recognise if a patient was in discomfort or not.  Additionally, it is important to consider the language used, tone and volume of spoken words whilst ensuring that you do not speak down to, over, or treat them like a child. This is support by Williams and Herman (2011), who found that the tone in which residents were spoken to often correlated with their compliance with care. Residents who were spoken to like a child often resisted care and demonstrated behaviour such as screaming and crying (Williams and Herman 2011). 

According to the Royal College of Nursing (date), good team working means that services are organized creatively, appropriate decisions are made, patients receive high quality services and teams are able to respond efficiently to unexpected change. In order to optimise the care of patients, it is vital that all members of the team, including the patient, communicate with each other. This includes combining their observations, expertise and decision making responsibilities in order to operate as an effective team (WHO DATE). Patient safety can be positively impacted by effective teamwork. Nowadays it is rare that patients will be looked after by on professional alone and their care usually falls to a multidisciplinary team. In order to provide the optimum patient care and treatment, multidisciplinary teams are comprised of healthcare professionals with different skills, abilities and expertise. The need for these specialised teams has been amplified in recent years due to the increase in chronic disease, co-morbidities and an ageing population. (WHO, 2012). This means that effective team work is vital in order to reduce the likelihood of errors being caused by miscommunication between teams, and misunderstandings the roles and responsibilities within that team.  Research has also shown that the involvement of patients in their care, as part of the team, can also help to decrease the possibility of any errors or adverse events (NICE, 2016).

In order for these teams for work effectively, it is important that the whole team is focused on the common purpose of providing the best patient care. In order to do so, it is essential that the different skills and expertise of the all members of the team are utilised. (Royal College of Nursing, 2016).  This is supported by the NMC Code (2018), which states that staff should “respect the skills, expertise and contributions of your colleagues, referring matters to them when appropriate” (Page 9).  All members of the team should be kept informed at all times of any changes to patient care and they should also be given the opportunity to have their own say on any changes.

According to Weller et al (2014), there are there are three domains to the challenges to interprofessional teamwork which are educational, psychological and organisational. Education can cause challenges to effective teamwork due to the fact that different health care professionals such as doctors and nurses are trained on differing programmes. This can lead to the groups not having an understanding each other’s roles, responsibilities and priorities. They may also have differing expectations in relation to content, structure and timings which may contribute to problems within the multidisciplinary team. A psychological factor is hierarchical structures in healthcare can also be a barrier to effective teamwork. Staff may feel uncomfortable with challenging decisions of more senior staff which may lead to them concealing their concerns. This hierarchical structure can lead to catastrophic consequences, which was evident in the case of Elaine Bromiley which will be discussed in more detail, later in the essay.  And finally, organisational challenges such as geography, for example, the geographical locations of patients within a hospital. This may make it difficult to schedule meetings to discuss patient care plans and ward rounds. There are often multiple different healthcare professionals involved in a patients care and often they have to rely on opportunistic meetings in order to pass on information. (Weller, J et al 2014)

Research has found that medication errors are more likely to occur if there is poor communication between staff. It is essential that the correct medication, dose, route and time of administration are communicated between all members of the team. (Keers, Williams, Cooke & Ashcroft, 2013).  Furthermore, a recent study carried out by Lyubovnikova et al (2015) found a correlation between teamwork and a range of patient outcomes such as patient mortality and errors. The report states that “Where more errors are being made, patients are clearly at greater risk.”  The most likely errors found to occur are medication errors, omission of care and errors of commission.  This demonstrates the significance teamwork has in hospital when it comes to saving patients lives. It also found that hospitals in which staff reported good teamwork characteristics had significantly lower rates of workplace injuries and staff sickness absence which is also beneficial for the hospital and staff morale.

The case of Victoria Climbie highlights the dire consequences that can result from poor teamwork. In an inquiry into her death the Laming Report (2003) found that there were 12 occasions on which the local services had failed to protect Victoria. These failings were found to be a result of poor communication and information sharing between different teams involved in the case and inadequate staff training. The NMC Code (2018) states that staff must “keep colleagues informed when you are sharing the care of individuals with other health and care professionals and staff”. It would appear that this was not the case with Victoria, as different teams failed to share information which could have potentially changed the cases outcome. Similarly, poor teamwork was found to be one of the factors in the case of Elaine Bromiley. Elaine’s case highlights a lack of respect between members of the team. There were three nurses and three experience nurses present during the resus. On two occasions during the process the nurses attempted to intervene, with one presenting a surgical airway kit and another putting in place a bed in ICU. These suggestions were ignored or dismissed by the consultants. The dismissal of these attempts may have been a significant factor in the case. It later came to light that the nurses felt unable to approach the subject with the doctors. It is essential that all members of a team are able to demonstrate assertiveness and are able to provided suggestions, especially when there appears to be danger such as in the case of Elaine. The NMC Code (2018) states that staff should “respect the skills, expertise and contributions of your colleagues”. In Elaine’s case the contribution of the nurses was not respected by the other members of the team. The inquiry into Elaine’s death suggested that teams must “Ensure an atmosphere of good communication in the operating theatre such that any member of staff feels comfortable to make suggestions on treatment.” (Professor Michael Harmer 2005).  The inquiry also found that there were errors made during the handover from the transfer of care as the patient was not formally transferred from the care of the anaesthetists to recovery staff.  The inquiry states that “There was no clear transfer of care in this case between Dr A and the recovery staff.”  It was suggested by Professor Harmer (2005) that in future there must be a more formal handover to ensure that there is no confusion over who is responsible for the patients care.

The importance of teamwork in healthcare environments was also emphasized during recent placements. During my placement at the aforementioned Nursing home I noticed the importance the multidisciplinary team plays in the everyday care of the residents. The residents’ personal care is primarily undertaken by the carers however it is essential that information about the patients care is shared amongst all members of the tem including the care staff, nursing staff, district nurses, doctors and other health care professionals. Whilst working alongside the RGN at the nursing home I began to recognise the importance of effective teamwork, for example, when administering drugs such as insulin. At various times throughout the day the diabetic residents need to have their blood glucose levels tested and be given an insulin injection. Before this can be administered it is vital that the RGN knows whether or not the resident has had eaten in order to correctly assess the patients’ blood levels. According to the NICE (2015) guidelines, not eating enough can cause diabetics to become hypoglycaemic. If the patient has not eaten their bloody glucose level may be too low to administer the insulin injection as it will lower the blood glucose level further. Therefore, it is essential that all members of the team share information about the residents with one another so that their needs can be assessed accurately. This ensures that the nurse works in line with the NMC Code (2018) which stipulates that nurses must “work with colleagues to preserve the safety of those receiving care”. I also observed the benefits of an effective multidisciplinary care team whilst on a recent placement at a medical centre. A baby had come into the medical centre for vaccinations with the practice nurse. The mother of the baby expressed concerns that see had notice a small rash on the baby’s body and that it may not be suitable for him to have the vaccinations encase he had a virus. The baby’s medical records indicated that he had been seen by a GP at the medical centre a few weeks earlier for a chest infection. Considering this the practice nurse decided that it would be best to consult the GP before administering the vaccinations. The GP examined the baby and advise that as he had no fever and appeared well it would be safe to proceed. The nurse in this situation referred the patient to the GP in order to obtain his expertise as she was unsure of how to proceed. These actions adhere to the code set out by the NMC (2018) that states nurses should “respect the skills, expertise and contributions of your colleagues, referring matters to them when appropriate”.

This essay has discussed the role that communication and teamwork play and their importance in nursing. It is evident that communication and teamwork go hand in hand in a nursing role and that you cannot have effective teamwork without good communication. The essay has considered what constitutes good communication and the barriers that nurses may encounter that may cause communication to become ineffective. When considering cases such as the Francis Inquiry (2013), we are able to observe the outcome and impact that poor communication can have on NHS Trusts. Such cases are beneficial to help nurse and other healthcare professionals learn from past mistakes and avoid such errors in future. Reflection on placement experiences has helped to demonstrate how adapting communication can help in the care of patients with Dementia. It is important to remember that not all patients are the same and communication must be adapted accordingly. For this reason it is vital that nurses are able to exercise good communication in all forms, verbal and non verbal. Nurse must also be able to interpret patient’s behaviour in order to ensure they are communicating in the most effective way. With regard to teamwork, this essay has also discussed cases such as the Laming Inquiry (2003) and the Elaine Bromiley Inquiry (2005). These inquiries have both highlighted the consequences poor teamwork can have on patient care and they put in place recommendations to make sure incidents like this can be prevented in the future. Drawing on placement experiences has shown how the NMC Code (2018) relates to clinical situations and how nurses are able to adhere to them in order to put the best interest of their patients first. In future it would be valuable to consider further how additional training can help optimise both communication and teamwork for nurses and all healthcare professionals alike.

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