HEALTHCARE experiences make for common stories from family, friends, and colleagues. Positive experiences may stem from the multidisciplinary team's effective use of both collaboration and communication. Negative experiences may result from ineffective communication among the healthcare staff or with patients and families. Effective communication between healthcare professionals, patients, and families via collaborative conversations is essential to patient safety and optimal outcomes.
For the purposes of this article, the authors have developed the concept of collaborative conversations, which are defined as dynamic, informative, and constructive discussions in which knowledge and information are shared to promote situational awareness in healthcare settings. Below, the authors discuss the role of collaborative conversations for clinical staff and the importance of including patients in discussions regarding their care.
Poor communication leads to adverse events
According to The Joint Commission, issues in communication account for 59% of serious and preventable adverse events.1 Similarly, the National Academy of Medicine (formerly the Institute of Medicine) reports that hospitals can prevent diagnostic errors by improving communication, and the Agency for Healthcare Research and Quality (AHRQ) reports a pervasive problem with communication in healthcare, potentially leading to patient harm.2,3
The Controlled Risk Insurance Company (CRICO) is the risk management foundation of Harvard Medical Institute. The organization has tracked approximately 320,000 compiled medical malpractice cases from more than 400 US hospitals, reporting that 30% of these claims result from failures in communication.4 According to Heather Riah, assistant vice president of CRICO Strategies, these incidents are not isolated to provider explanations, language barriers, or deficits in understanding. Instead, all aspects of healthcare are at risk for inefficient communication.4 CRICO also reported a direct link between malpractice lawsuits related to ineffective communication and potential surgical complications.4
The Interprofessional Education Collaborative (IPEC) addresses the need to prepare healthcare professionals by developing core competencies for interprofessional collaboration while providing safe, high-quality healthcare.5 IPEC provides education, tools, and resources to universities, healthcare institutions, and government agencies. It recognizes the need for communication, teamwork, mutual respect, shared values, and an understanding of the scopes of practice between providers.5
Because ineffective communication can occur at any level of healthcare, The Joint Commission included “Improve Staff Communication” in both its 2019 and 2020 National Patient Safety Goals, reinforcing the need to better these practices.6,7 Collaboration and communication among healthcare professionals within the multidisciplinary team can help prevent medication errors and other mistakes.8 Additionally, AHRQ recognizes the role of patients and their families as key determinants of safety in healthcare settings.9
Including patients and families as integral members of the healthcare team provides an opportunity for them to express safety concerns to be addressed by healthcare professionals.10 If they do not feel comfortable raising issues with the staff, patients may fail to express these concerns and subsequently place themselves at risk.3
Overcoming barriers to communication
Healthcare settings can be stressful, highly charged environments, increasing the need for collaboration. Collaborative conversations allow members of the healthcare team to think creatively, understand the desired outcomes, make decisions, develop solutions, define a shared process, disagree without arguing, and reduce conflicts.
According to the American Nurses Association (ANA) and the American Organization of Nurse Executives (AONE), “Communication, particularly in high-intensity environments such as health care, is not merely the transaction of words. Effective communication requires an understanding of the underlying context of the situation, an appreciation for the tone and emotions of a conversation, and the accurate information.”11
The ANA and AONE published principles for collaborative relationships between nurses and nurse managers.11 They can be used to promote collaborative conversations throughout the healthcare team, as well as with patients and families, and may include effective communication, authentic relationships, and a culture of learning. The principles of collaborative communication include:11
- active listening
- ensuring accurate communication
- sharing knowledge
- understanding the message, its purpose, and the associated expectations
- fostering open, safe environments
- communicating to the appropriate individuals
- cultivating authentic, caring relationships with patients and colleagues
- respecting others' personalities, needs, and wants
- empowering and inspiring others to share ideas and recognizing and leveraging strengths
- learning from mistakes
- being clear on individual wants and needs but remaining open to negotiation.
Implementing key principles
Certain strategies are instrumental in fostering collaborative communication for improved patient outcomes. These include the read-back strategy, the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) approach, the situation-background-assessment-recommendation (SBAR) protocol, the comprehensive unit-based safety program (CUSP), and methods to address incivility.3,12-14
Read-back strategies foster collaborative conversations among clinicians as well as between clinicians and ancillary healthcare departments such as the lab. According to AHRQ, read-back strategies improve communication surrounding critical patient test results and are considered a standard practice.3 An increase in the number of patients and staff who speak English as a second language increases the risk of communication errors.15 This strategy helps clinicians avoid misunderstandings by requiring them to repeat critical lab values.
The TeamSTEPPS approach is an evidence-based program created by AHRQ and the Department of Defense following 3 years of research and development to address the landmark report from the Institute of Medicine (now the National Academy of Medicine), To Err is Human.16,17 This approach improves quality and safety by creating effective, productive teams to optimize resources, resolve conflicts, improve information sharing, and achieve positive patient outcomes.18 It is also utilized to enhance team collaboration.
Although interdisciplinary teamwork is necessary to improve patient safety and outcomes, not all healthcare professionals are trained together. The TeamSTEPPS program, which can be integrated into training for staff of every discipline and level, utilizes skills and strategies to improve teamwork, communication, and collaboration in healthcare organizations.3 It includes training material and a curriculum on leadership, situational monitoring, mutual support, and communication skills for institutional integration.16
Several organizational healthcare systems, such as Duke University Health System and the University of Minnesota, have adopted TeamSTEPPS to improve collaboration and safety. These institutions will serve as Team Resource Center Training sites for the national initiative.13
SBAR is another communication strategy utilized in many healthcare settings. It is used by healthcare professionals to explain patient situations, backgrounds, assessments, and any recommendations. For example, nurses transferring a patient from the postanesthesia care unit to a surgical unit would use SBAR to ensure effective communication during patient handoff.14
CUSP is a five-step method to help healthcare institutions identify and address any system defects that may lead to negative patient safety outcomes.19 It utilizes tools, resources, teamwork, and evidence-based best practices to address required improvements on a specific unit, such as medical, in a specific healthcare setting, such as a hospital.3,20
Methods to address incivility are vital in healthcare organizations, as incivil cultures may have a negative impact on communication and teamwork.3,20,21 Quality improvement programs that increase awareness, provide cognitive rehearsal techniques and resources, and include management in the improvement program can help decrease incivility.22 The ANA aims to protect nurses from incivility through advocacy, policy, and resources to foster healthy, safe, and respectful work environments that lead to positive health outcomes.19,22,23
Progress in communication
Many healthcare organizations provide training programs to improve communication within the multidisciplinary team. According to AHRQ, “a growing body of literature demonstrates that improved team behaviors lead to better patient outcomes.”16 To this end, healthcare organizations are also working to address disruptive and unprofessional behaviors such as incivility and bullying.16
Effective teamwork requires coordination, cooperation, and collaborative conversations for all of those involved in patient care, including the patients themselves. Their cooperation can assist the entire healthcare team and facility in providing exceptional care and positive outcomes.24
1. The Joint Commission. Advancing effective communication, cultural competence, and patient- and family-centered care: a roadmap for hospitals. 2010. http://www.jointcommission.org/assets/1/6/aroadmapforhospitalsfinalversion727.pdf
2. Institute of Medicine. IOM: poor communication leads to diagnostic errors. Case Management Insider. 2015. http://www.hcpro.com/CAS-321807-12341/IOM-Poor-communication-leads-to-diagnostic-errors.html
3. Agency for Healthcare Research and Quality. Communication between clinicians. PSNet. 2019. https://psnet.ahrq.gov/primer/communication-between-clinicians
4. Maktabi M, Ruoff G. Communication failures in medical malpractice – lessons learned from the CRICO strategies' comparative benchmarking system. ASA Monitor
. 2017;81:20–22. https://monitor.pubs.asahq.org/article.aspx?articleid=2599456
5. Interprofessional Education Collaborative. IPEC core competencies for interprofessional collaborative practice: 2016 update. 2016. http://www.asha.org/uploadedFiles/Interprofessional-Collaboration-Core-Competency.pdf
6. The Joint Commission. 2019 National Patient Safety Goals. 2019. http://www.jointcommission.org/assets/1/6/2019_HAP_NPSGs_final2.pdf
7. The Joint Commission. 2020 Hospital National Patient Safety Goals. 2019. http://www.jointcommission.org/assets/1/6/2020_HAP_NPSG_goals_final.pdf
8. Manias E. Effects of interdisciplinary collaboration in hospitals on medication errors: an integrative review. Expert Opin Drug Saf
9. Agency for Healthcare Research and Quality. Culture of safety. PSNet. 2019. https://psnet.ahrq.gov/primer/culture-safety
10. Smith M, Saunders R, Stuckhardt L, et al Engaging patients, families, and communities. In: Best Care at Lower Cost: The Path to Continuously Learning Health Care in America
. Washington, DC: National Academies Press; 2013.
11. American Nurses Association; American Organization of Nurse Executives. ANA/AONE principles for collaborative relationships between clinical nurses and nurse managers. Nurse Leader
12. Boyd M, Cumin D, Lombard B, Torrie J, Civil N, Weller J. Read-back improves information transfer in simulated clinical crises. BMJ Qual Saf
13. Agency for Healthcare Research and Quality. TeamSTEPPS Regional Training Centers. 2017. http://www.ahrq.gov/teamstepps/instructor/regionaltrainingcenters.html
14. Institute for Healthcare Improvement. SBAR tool: situation-background-assessment-recommendation. 2019. http://www.ihi.org/resources/Pages/Tools/SBARToolkit.aspx
15. Meuter RF, Gallois C, Segalowitz NS, Ryder AG, Hocking J. Overcoming language barriers in healthcare: a protocol for investigating safe and effective communication when patients or clinicians use a second language. BMC Health Serv Res
16. Agency for Healthcare Research and Quality. TeamSTEPPS 2.0. 2019. http://www.ahrq.gov/teamstepps/instructor/index.html
17. Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System
. Washington, DC: National Academies Press; 2000.
18. Bhatt J, Swick M. Focusing on teamwork and communication to improve patient safety. American Hospital Association. 2017. http://www.aha.org/news/blog/2017-03-15-focusing-teamwork-and-communication-improve-patient-safety
19. Paine L, Sawyer MD. On the CUSP: how to implement a comprehensive unit-based safety program. American Nurse Today
. 2014. http://www.americannursetoday.com/on-the-cusp-how-to-implement-a-comprehensive-unit-based-safety-program
20. Agency for Healthcare Research and Quality. The CUSP Method. 2019. http://www.ahrq.gov/hai/cusp/index.html
21. Kroning M. Be CIVIL: committing to zero tolerance for workplace incivility. Nurs Manage
22. Warrner J, Sommers K, Zappa M, Thornlow DK. Decreasing workplace incivility. Nurs Manage
. 2016;47(1):22–30; quiz 1.
24. Morley L, Cashell A. Collaboration in health care. J Med Imaging Radiat Sci