Module 2:  Interprofessional Communication

Objectives

  1. Define "communication".
  2. Describe the attributes of effective communication and teamwork, as well as identify potential barriers.
  3. Understand and begin to apply the CUS (Concerned, Uncomfortable, Safety) and SBAR (Situation, Background, Assessment, Recommendation) models of communication within teams.
  4. Explore select elements of personality on effective team communication.
  5. Appreciate the influence of non-verbal aspects of communication.
  6. Understand the basic elements of conflict resolution.

Overview

The Interprofessional Education Collaborative (IPEC) considers communication as a ‘core aspect of interprofessional collaborative practice’ (2011, p. 22). This module provides the learner with basic terminology, offers recommended literature on communication within healthcare teams, presents helpful models of communication to enhance teamwork, and examines elements that can enhance as well as detract from effective interpersonal interactions for healthcare teams.

Communication

Merriam-Webster defines communication as “a process by which information is exchanged between individuals through a common system of symbols, signs, or behavior; exchange of information, or personal rapport”.

Therapeutic communication used in health care and among effective interprofessional teams is a complex process necessary to ensure patient safety and quality outcomes. Schuster and Nykolyn (2010) characterize highly effective communication competency as including the ability to: (a) “choose communication behaviors that are effective and appropriate for a given situation; (b) be sensitive to the perspectives of others; and (c) achieve communication goals in a manner that maintains or enhances the relationship in which it occurs” (p.12).

IPEC (Interprofessional Education Collaborative) produced four general competencies for interprofessional collaborative practice and the example behavioral expectations. The behavioral expectations of interprofessional communication include:

  1. Choose effective communication tools and techniques, including information systems and communication technologies, to facilitate discussions and interactions that enhance team function.
  2. Organize and communicate information with patients, families, and healthcare team members in a form that is understandable, avoiding discipline-specific terminology when possible.
  3. Express one’s knowledge and opinions to team members involved in patient care with confidence, clarity, & respect, working to ensure common understanding of information treatment & care decisions.
  4. Listen actively, and encourage ideas and opinions of other team members.
  5. Give timely, sensitive, instructive feedback to others about their performance on the team, responding respectfully as a team member to feedback from others.
  6. Use respectful language appropriate for a given difficult situation, crucial conversation, or interprofessional conflict.
  7. Recognize how one’s own uniqueness, including experience level, expertise, culture, power, and hierarchy within the healthcare team, contributes to effective communication, conflict resolution, and positive interprofessional working relationships.
  8. Communicate consistently the importance of teamwork in patient-centered & community-focused

 If all team members are not effective in engaging in the above behaviors, team communication, and ultimately patient safety, can suffer. Helping interprofessional student teams engage in self-reflection can lead to positive interactions, team member accountability, and individual practitioner growth of communication skills.

 

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Positive and Negative Teamwork Communication  

The concepts of interpersonal communication and interpersonal relationships form the basis for effective communication and teamwork in healthcare; “Interpersonal communication is a form of communication that is used when we view others as unique individuals and interact with them for the purpose of maintaining an ongoing relationship” (Schuster & Nykolyn, 2010, p.13). Effective communication and teamwork begins with the recognition that each member of the team has unique skills and abilities to offer and deserves to be engaged in respectful interactions with other team members. A healthy respectful ongoing relationship is the goal of healthcare team communications. The absence of components of effective communication lead to barriers for the development of effective healthcare teams. Effective healthcare communications must be open, honest, nonjudgmental, and based on each team member having an equal standing on the team.  Schuster and Nykoln (2010) define four components of high-level communication competence:

  • Effectiveness: the message sent must be the message received. Communication between team members must be clear and concise.
  • Sensitivity: each member of the team must be sensitive to the needs and perspectives of the other members. Communications should not be purposely insensitive to the role of other team members.
  • Appropriateness: team communications should be adapted to the individual situation at hand. Some situations may require more or less direct communication styles and the team must be able to adapt as needed.
  • Saving face: maintaining or enhancing relationships must remain the ultimate goal of health team communications. A team cannot be effective if the internal relationship of the practitioners involved is not maintained.

Effective communication among health team members mirrors effective communication strategies in practitioner-client interactions. Antai-Otong (2007) suggests the following components as evidence of effective communication patterns:

  • Active listening
  • Good eye contact (culturally appropriate)
  • Open body language
  • Paraphrasing
  • Reflective listening
  • Appropriate distance
  • Congruent verbal and nonverbal body language
  • Normal voice tone (no shouting)

In addition, Antai-Otong suggests the following requirements for effective communication necessary for effective healthcare team work:

  • Rapport: “harmonious, empathetic, and mutually respectful relationship” (p. 28). Rapport requires an acceptance and understanding of fellow team members.
  • Trust: indicates each team member can depend on the other team members. To feel trust, team members must not fear the interaction will be inconsistent with previous interactions or that the interaction will end in embarrassment or other negative emotions. Several things engender trust in others: competence, reliability, confidence, predictability, trustworthiness, genuineness and authenticity, consistency, and fairness.

Tools for Teaching Effective Communication: SBAR and CUS

SBAR and CUS materials can be obtained at: http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/essentials/pocketguide.html#cus

There are many communication tools that can assist healthcare teams in being effective and efficient. The Agency for Healthcare Research and Quality (AHRQ) developed tools to enhance healthcare team communication and, as a result, improve patient outcomes and safety. Two such tools quite effective in improving effective communication with healthcare teams are SBAR and CUS. Both of these tools enhance team members’ abilities to resolve conflict in respectful ways that will maintain the integrity and effectiveness of the team.

SBAR stands for Situation, Background, Assessment, and Recommendation. Using a detailed and consistent rubric to guide communication is one way to ensure every health provider involved in a case is giving and receiving consistent and complete communication so a safe patient care decision can be made.

SBAR explained:

Situation: What critical event is occurring with the patient?

Background: What is the clinical background or context surrounding the situation? What lab results or vital signs have changed?

Assessment: What do I think the problem is?

Recommendation: What would I do to correct it? What action do I want to see?

CUS stands for Concerned, Uncomfortable, and Safety. Using CUS provides practitioners and assertive way to communicate the gravity and importance of fast-changing clinical situations.

CUS explained:

“I am Concerned”: focuses on the aspects of the situation that pose concern to the health care provider

“I am Uncomfortable”: speaks to the intuitive nature of health care and alerts others to the “gut” reaction of the health care provider.

“This is a Safety issue!” Once this statement is spoken, it is time for everyone to stop and reevaluate the situation and what steps need to occur to safely care for the patient.

Personality and Effective Communication

How do you best communicate? Although you have two hands, you prefer to use one over the other.  When you use your preferred hand, you find that your writing is easy and natural, and takes little effort.  Chances are the writing is what you expected.  Writing with your non-preferred hand most likely is awkward, and takes more effort, concentration and time.  Perhaps the result would not be what you desired.  Note, however, that you are able to write your name with either hand if you want.  If something were to happen to your preferred hand, you probably would begin to use the non-preferred hand.  Through concentration and greater time and effort, the writing would eventually approach that achieved with your preferred hand. Personality and communication styles are similar. You have preferred tendencies that impact how you communicate with others.

According to Kiersey and Bates (1984), there are four main categories of personality types. Each type interacts with the world and others in unique ways. Each personality type is assigned a four-letter code to describe the person’s communication and personality differences. For example, people are labeled as either E (extrovert) or I (introvert). The E and I designations refer to a person’s source of energy. For example, following a day of conference attendance, the extrovert will be excited to go to dinner with people they have met throughout the day. Their energy and enthusiasm builds as they interact with others. On the other hand, the introvert may prefer some alone time to re-energize and escape to their room to enjoy room service and a good book. The second letters S (sensing) and N (iNtuition) refer to a person’s preferred method of gaining information. Differences in the way Sensing individuals and Intuiting individuals gain information from the environment around them account for more miscommunication and misunderstandings than any of the four categories. A sensor wants, needs and trusts facts as their primary source of information while an intuitive person prefers to consider possibilities and potential. The intuitive person is often seen as a daydreamer who focuses on the possibility of what may be rather than the reality of what has been. The third letters T (thinking) and F (feeling) refer to a person’s preferred decision making process.  For example, a thinker approaches decisions in an impersonal and unbiased manner while a feeler takes emotions and “feelings” of those involved into account. According to Kiersey and Bates, this is the only pair of characteristics that show a gender trend with 60% of females identifying as Feelers. The final letters J (judgment) and P (perception) refer to a person’s preferred way of relating to the external world. For example, a judger prefers closure and a decision in most situations while a perceiver prefers options and open-ended situations.

As you can imagine, each style preference impacts one’s communication style. The table below illustrates just a few of the preferred communication styles based on Kiersey Temperament composites. Knowing the composite of your team members will enhance your ability to communicate effectively with each member and illuminate some situations that my provide frustration in the communication process.

Preferred Communication Styles

Extrovert Introvert Sensing Intuition Thinking Feeling Judgment Perception
Respond quickly to inquiries Take time to think inwardly before responding Present evidence, facts, and details first Present insights, ideas, and concepts first Prefer brief and concise communication Prefer social and friendly communication (enjoy small talk) Discuss schedules and timetables Dislike schedules and timetables
Respond outwardly with enthusiasm and energy Need to be invited to speak or share thoughts Focus on practical and realistic Focus on future opportunities and possibilities Convince others by impersonal and logical thinking Convince others with personal meaning and enthusiasm Expect others to move from thoughts to conclusions Realize conclusions may not always be reached
Think out loud Reflective Step-by-step presentations Round-about presentations See others’ flaws See others’ point of view Talk with purpose and direction Talk about flexibility and change
Prefer to interact with others Share most readily with those known well Follow agendas and time frames Digress from agendas: they often get in the way of the meeting Present goals and objectives first Begin with pleasantries then move on to business Focus on content of a discussion Focus on process of a discussion

Take the Kiersey Temperament Sorter and compare your results with others on your team. Does this explain some of the frustration you have with others who communicate differently than you? How can you make adjustments to minimize communication frustration on your team?

Impact of Non-Verbal Communication

Non-verbal communication accounts for a large percentage of the message conveyed to others in all situations. Schuster and Nykolyn (2010) cite several aspects that make up non-verbal communication. These aspects include gestures, facial expression, and tone of voice. In addition, Dane Archer, a Professor at the University of California at Santa Cruz has included other aspects: personal space, appearance, and cultural implications. In his online activity, Exploring Nonverbal Communication, Professor Archer provides explanations of the aspects of nonverbal communication supplemented by video segments.

Non-verbal messages are our way of communicating, even if we don’t intend to. According to Qubein (1997), approximately 93% of communication is conveyed by the nonverbal. Nonverbal may be referred to as a “relational dimension” of communication (Schuster & Nykolyn, 2010). The “how” of what is being communicated. Many qualities of the voice impact the actual message that is received. Those who are interested in becoming better communicators often focus on these qualities of voice, leading to a 38% change in the overall perception of their communicated messages (Qubein, 1997): (a) volume and pace of speech; (b) intonation; (c) stress on particular words; (d) juncture-how vowels and consonants are joined; (e) laughing, crying, yawning & sighing. In addition, body language impacts one’s conveyed message: (a) posture; (b) voiceless signals-eye contact; (c) hand gestures; (d) facial expressions; (e) grooming and appearance; and (f) use of touch and personal space.

Helping health professions students experiment with these nonverbal aspects and providing objective feedback will help them mold their personal communication style for effectiveness with patients and peers alike.

Conflict Resolution

The Dale Carnegie Training Center provides many free e-book resources (and training options) for team conflict management. An initial resource that is useful on an individual level for all team members is the Internal Conflict Resolution Guidebook. This free e-book walks individuals through the process of analyzing their personal style of conflict reaction style and provides strategies for reducing conflict in the workplace. The Team Conflict Resolution Strategies e-book outlines and expands on the following 11 strategies to team conflict resolution:

  1. Clearly define and agree on the exact issue that is causing the team distress.
  2. Prepare and be specific.
  3. Have a positive attitude.
  4. Walk in the other person’s shoes.
  5. Look for similarities.
  6. Deal with facts, not emotions.
  7. Present facts and evidence, provide suggestions and alternatives.
  8. Establish open communication…Listen first and speak second.
  9. Demonstrate interest in the other person’s point of view.
  10. Explore options and possible solutions together.
  11. End on a positive note, reaffirm the goals.

Debriefing to Encourage Learning

     The post-simulation debriefing period offers a forum to review performance, assess thought processes/frame of mind, and plan for improved performance on future sessions. “A desired outcome of debriefing is clinical judgment development” (Lusk & Fater, 2013, p. 16). The benefits of debriefing were first realized in military aviation training sessions followed by education, medicine, and nursing. In nursing, the positive effects of debriefing include: increased student confidence, improved satisfaction, cognitive competence and knowledge acquisition. Lessons learned about debriefing; Successful debriefings:

  • Have facilitators who exhibit trust, support and listening in a safe, nonjudgmental environment
  • Last as long or longer than the simulation scenario (but at least 20 minutes)
  • Engage 14 or fewer learners at a time
  • Utilize a structured debriefing framework

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Debriefing as Formative Assessment

Formative assessment provides feedback to learners during the learning process so they can make adjustments and emerge with greater knowledge, skill, or ability. Debriefing as formative assessment involves four key steps for success (Rudolph, Simon, Raemer, & Eppich, 2008).

  1. Identify the gap between desired and actual performance.
  2. Provide feedback by describing actions with specific details.
    1. “I saw…”
    2. “I heard you say, …”
    3. “I noticed…”
  3. Inquire about the process using open-ended questions. LISTEN to the response.
    1. “I wonder, could you walk me through your thinking when…”
    2. “I’m curious what was going through your mind when…”
    3. “What’s your take on…”
  4. Address the processes via discussion, lecturette, coaching, or modeling.
    1. Tailored to the learner’s thinking
    2. Based on faculty expertise and experience

“Actionable feedback targeted to the learner’s needs is one of the strongest predictors of improved performance in learning” (Rudolph & Raemer, 2013, p.186).

     Frame-based feedback focuses on the learner’s frame of mind during clinical encounters rather than primarily focusing on correcting actions. This form of debriefing feedback focuses on “why” of the mistake (inaccurate learner thoughts that guide their actions) rather than the “what” of the mistake. Frame-based feedback is accomplished in three steps:

  • Instructor describes their view of how the learner is doing
    • Description must be unambiguous and specific
  • Instructor asks questions to ascertain the learner’s immediate needs (based on the learner’s frame of mind during the scenario)
  • Instructor provides direct instruction that meets the learners needs
    • Hold to the basic assumption that the learner is intelligent, capable, and well-intentioned (Rudolph & Raemer, 2013)

References

Antai-Otong, D. (2007). Nurse-Client Communication: A lifespan approach. Sudbury, MA: Jones and Bartlett Publishers.

Dreifeurst, K. (2012). Using Debriefing for Meaningful Learning to Foster Development of Clinical Reasoning in Simulation. Journal of Nursing Education, 51, 326-333.

Interprofessional Education Collaborative (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative. Retrieved from http://www.aacn.nche.edu/education-resources/ipecreport.pdf

Jeffries, P. (2005). A Framework for Designing, Implementing, and Evaluating: Simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96-103.

Kiersey, D. & Bates, M. (1984). Please Understand Me: Character & Temperament Types. Del Mar, CA: Prometheus Nemesis Book Company.

Lusk, J.M. & Fater, K. (2013). Postsimulation Debriefing to Maximize Clinical Judgment Development. Nurse Educator, 38(1), 16-19.

Qubein, N.R. (1997). How to be a Great Communicator: In person, on paper, and on the podium. New York, NY: John Wiley & Sons, Inc.

Rudolph, J. & Raemer, D. (2013). We Know What They Did Wrong, But Not Why: The case for ‘frame-based’ feedback. The Clinical Teacher, 10, 186-189.

Rudolph, J.W., Simon, R., Raemer, D.B., & Eppich, W. (2008). Debriefing as Formative Assessment: Closing performance gaps in medical education. Academic Emergency Medicine,15(11), 1110-1116.

Rudolph, J.W., Simon, R., Defresne, R.L., & Raemer, D.B. (2006). There’s No Such Thing as a “Non-judgmental” Debriefing: A theory and method for debriefing with good judgment. Simulation in Healthcare, 1(1), 49-55.

Schuster, P.M. & Nykolyn, L. (2010). Communication for Nurses: How to prevent harmful events and promote patient safety. Philadelphia, PA: F.A Davis Company.