The concept of a healthy work environment is described by the American Association of Critical-Care Nurses (AACN) in its Standards for Establishing and Sustaining Healthy Work Environments. AACN has endorsed the first standard of skilled communication as the foremost skill a team must possess in order to work effectively. This standard suggests, "nurses must be as proficient in communication skills as they are in clinical skills."1 It focuses on nursing staff being proficient in the use of communication skills to not only provide quality patient care without errors, but also to facilitate interpersonal and interdisciplinary relationships and teamwork within the unit.
To work toward a healthier work environment, a team needs to be educated in the foundations of developing healthy relationships. Leadership must not only communicate, but also model those behaviors critical to its creation and continuance. To build healthy relationships, one must realize that the affiliations between nursing staff and leadership must reflect strength; critical to this strength is a freedom of open and trusting communication. The AACN states that "relationship issues are real obstacles to the development of work environments in which patients and their families can receive safe, even excellent care. Inattention to work relationships creates obstacles that may become the root cause of medical errors, hospital-acquired infections and other complications, patient readmissions, and nurse turnovers."2 Team member relationships and effective communication are key to optimal patient care and a healthy work environment for nurses.
The team building series
Good relationships between team members must be based on trust, respect, open communication, and support. The nurse leader's role is to sustain these relationships by providing the tools, knowledge, supplies, and mentoring support needed to facilitate patient care. To this end, front-line nurse leaders and administration partnered with The Center for Professional Development and Education to establish a series of five team building sessions to increase awareness of the differences between team members, enhance communication, increase teamwork, and aid staff in resolving conflict in order to attain a culture of a healthy work environment. This culture change not only supports an enhancement of the work environment, but also increases job satisfaction and encourages the delivery of quality patient care.3,4
Team building sessions included a personality assessment, a session on generational awareness, a horizontal hostility in-service, a presentation on conflict management, and a customer service seminar. Given the deliberate ordering of the five sessions, staff members were positioned to work from introspective reflection toward an understanding of others. Ultimately, the series was designed to allow staff members to learn about themselves and to extend that learning into understanding the differences in others, while facilitating interaction, communication, and the management of conflict.
Consecutive sessions were offered every other month for 1 year and at varied times to ensure the participation of all nursing staff on all three shifts. The sessions were mandatory, guaranteeing full staff participation. Each session was attended by the director and nurse leader, attesting to their continued commitment to the culture change. Sessions were led by a nurse educator and included both an activity and facilitated discussion. Excellent sharing and communication were observed, as well as a celebration of teamwork.
The Personality Assessment session started the educational process, promoting self-awareness and informing team members of the group's composition by establishing group norms. The session allowed for the growth of self-awareness and self-reflection as each team member participated in a personality assessment. This activity promoted teamwork by an increased awareness of various personality types and offered suggestions for the various interactions required to effectively approach and work with each type.
The Generational Awareness session was a dynamic, interactive session, which educated staff members about the differing styles among the generations, with focus on interactions to support team functioning. Listening, inquiry, and dialogue served to facilitate team awareness of all perspectives, fulfilling many key elements of the AACN standard. Differences were recognized through an activity that formulated each member's generation and then discussed during a facilitated conversation about interactions between the generations. Specific interventions were mentioned and reviewed with staff members regarding how different generations can interact and work together effectively.
In order to fulfill the first standard of the AACN's healthy work environments standard of skilled communication, it's necessary to educate staff members about conflict management and horizontal violence. Although horizontal violence didn't exist in the unit at the time of creating the team building series, it was included as an educational program to increase awareness, define a culture of zero tolerance, and provide information to staff members about how to recognize horizontal violence. The session was designed to empower staff with the techniques necessary to combat horizontal violence.
The Conflict Management session educated staff members on how to resolve conflict with each other in an effective way. Both the Conflict Management and Horizontal Hostility sessions ultimately educated staff members about disrespectful behavior, abuse, and conflict and provided information about how to manage when facing difficult situations. Nursing leadership further solidified these sessions when they articulated a zero tolerance to horizontal violence.
The last session of the series, Customer Service, promoted listening, communication, and having fun at work. Staff members offered ways to include fun while performing their duties and were supported by leadership to include some of these tactics to increase their own job satisfaction. This session cemented the group's feelings of goodwill toward each other and ultimately promoted the teamwork idea within unit culture.
The strategies of the team building series enumerated below can aid the front-line nurse leader in promoting a culture of teamwork:
- ♦ Executive leadership support must be obtained.
- ♦ Team building sessions should be held every other month, over the course of 1 year, at times determined by the staff in order to keep everyone engaged in the team building process.
- ♦ All sessions should be mandatory and attended by the director and nurse leader of the unit to demonstrate importance, build trust, demonstrate commitment, and encourage communication between leadership and staff.
- ♦ Each session should be developed and facilitated by nurse educators in partnership with nursing leadership and include an activity, facilitated discussion, and periods of silence and time for storytelling, which promotes introspection, increased communication, and team building.
- ♦ Team norms should be established at the beginning of the first session. These are rules that a team agrees to follow as it conducts its work. Set expectations of trust, open communication, respect, and support and hold nursing leadership and nursing staff accountable to these ideals. For example, team norms during the team building sessions included the following: (1) the sessions were mandatory and attendance was necessary to the success of building the team; (2) in order to instill deep respect among all staff, staff members were asked to agree to trust, respect, openly communicate with, and support all their colleagues; (3) sessions were to be confidential, meaning that information shared during the sessions stayed within the session; (4) the sessions should be FUN. Staff members agreed to get the most out of each session by being present and willing to participate. These strategies were effective in creating a team atmosphere and specifically enforced its necessary component in the daily work of the unit.
In order to accomplish building a new team through this series of educational sessions, nurse leaders must be prepared to meet a few roadblocks along the way as our team did. A few staff members made it clear during our team building journey that they didn't wish to participate. These staff members made it difficult for the leaders of the unit by continually having other pressing things that kept them from attending the sessions. A lack of involvement within some sessions was also noted. At times during the educational sessions, staff members were asked to participate in an activity; however, some of them chose not to participate, leading them to not realize the entire benefit of the session.
After each session, evaluations were handed out and at the conclusion of the entire series, an overall evaluation was distributed. Only two staff members handed back overall evaluations. Both had positive thoughts about the program. One staff member wrote "they are a nice way to incorporate new ideas in a nonstressed way, it was fun and informative." To better determine the benefits of the series, a more detailed data collection tool should be utilized to determine exactly what staff members think about their team before the series begins and after it ends. However, despite not collecting data before initiating the program and an apparent lack of enthusiasm and involvement noted by a few members of the staff, the educational series was a success as is noted in how effective our team has become in its communication skills.
1. American Association of Critical-Care Nurses. Standards for Establishing and Sustaining Healthy Work Environments
2. American Association of Critical-Care Nurses. AACN standards for establishing and sustaining healthy work environments: a journey to excellence. Am J Crit Care.
3. Robinson S. Cultivating teamwork in the ICU. Adv Nurs.
4. Brown MS, Ohlinger J, Rusk C, Delmore P, Ittman P, CARE Group. Implementing potentially better practices for multidisciplinary team building: creating a neonatal intensive care unit culture of collaboration. Pediatrics.
2003;111(4 Pt 2):e482–e488.