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Interprofessional Education and Collaboration
An Evidence-Based Approach to Optimizing Health Care
Edited by Jordan Utley, Cindy Mathena and Tina Gunaldo
240 Pages
As the health care industry continues to grow, it is critical that those entering health care careers possess interprofessional competency and a collaborative skill set. As such, the World Health Organization and academic program accreditors have amplified their calls for interprofessional training. This text guides the reader through the core competencies for interprofessional collaborative practice that have been set by the Interprofessional Education Collaborative (IPEC) and takes an inclusive approach to the education standards set by professional programs that are members of the Health Professions Accreditors Collaborative (HPAC), including the Commission on Accreditation of the Athletic Training Education (CAATE).
Authored by a team of experts representing seven health care professions, this text uses simple definitions and uniform terminology to supply a foundational basis for IPE and IPCP. Introductory topics include building professional knowledge of self and others, creating a culture for teams, building interprofessional relationships, and fostering collaboration. Later chapters move beyond the basics to provide guidance in leading interprofessional teams, managing conflict, and sustaining the interprofessional effort.
Interprofessional Education and Collaboration offers a unique pedagogical structure that links IPE concepts with IPCP strategies by connecting research with evidence-based practices. Case studies create opportunities to assimilate and discuss IPE concepts. To optimize student engagement and comprehension, each chapter contains the following valuable learning aids:
- Each chapter begins with a Case Study that presents a realistic IPCP scenario. At the close of each chapter, the case study is revisited to apply the chapter themes to the case study, and three to five discussion questions are supplied.
- Collaborative Corner sidebars aid comprehension with reflective questions or statements related to chapter topics. This feature will facilitate collaborative learning as students share their interprofessional perspectives.
- Tools of IPE sidebars equip readers with resources such as surveys, inventories, and activities to implement in their daily practice.
- EBP of Teamship sidebars showcase contemporary research articles and findings. This feature reinforces the connection between IPE and IPCP by summarizing relevant research and supplying corresponding evidence-based IPCP strategies.
Cindy Mathena, PhD, OTR/L
Communication and Teamwork
Uniform Terminology
Importance of Collaboration
Enablers and Barriers of IPCP and IPE
History of IPCP
History of IPE
Key Organizations and Resources
Summary
Chapter 2. Models of Delivery
Joy Doll, OTD, OTR/L; Anthony Breitbach, PhD, ATC, FASAHP; and Kathrin Eliot, PhD, RD, FAND
Theoretical Approaches
Foundation of IPE Teaching and Learning
Learning Strategies
Modes of Instruction
Models of Delivery
Clinically Integrated IPE
Summary
Chapter 3. Interprofessional Development for Clinicians, Preceptors, and Faculty
Jordan Hamson-Utley, PhD, LAT, ATC
Faculty KSAs and Behavioral Change
Development Models and Interprofessional Competencies
Organizational Models and Initiatives
Assessing Continuing Professional Education
Professional Development of the Clinical Preceptor
Summary
Chapter 4. Essential Evidence
Judi Schack-Dugré, PT, DPT, MBA, EdD; and Jordan Hamson-Utley, PhD, LAT, ATC
Influence of Faculty
Shaping IPE
Taking Aim
Learner’s Reaction (Level 1) Evidence
Change in Attitudes, Perceptions, Knowledge, and Skills (Level 2) Evidence
Behavioral Change (Level 3) Evidence
Organizational Change and Benefits to Patients (Level 4) Evidence
Influence of Online Delivery Models on Attitudes and IPCP
Effectiveness of Simulation
Assessment Tools
Summary
Chapter 5. Building or Rebuilding Interprofessional Relationships
K. Michelle Knewstep-Watkins, OTD, OTR/L; C. Michelle Longley, MSN, RN, NP-C; and Meghan Scanlon, BSIE
Evidence and Current Practice
Interprofessional Team Composition
Collaboration Tools and Team Activities
Summary
Chapter 6. Teaming to Achieve Patient and Organizational Outcomes
Robin Dennison, DNP, APRN, CCNS, NEA-BC; Amy Herrington, DNP, RN, CEN, CNE; and Melanie Logue, PhD, DNP, APRN, CFNP, FAANP
Health Care Teaming
Teams
Team Collaboration
Teaming and Outcomes
Organizational Systems and Team Practice
Strategies to Facilitate Teaming
Summary
Chapter 7. Interprofessional Communication Strategies
Dee M. Lance, PhD, CCC-SLP/L; and Kim C. McCullough, PhD, CCC-SLP/L
Overview of Team Communication
General Communication Strategies
Specific Communication Strategies
Summary
Chapter 8. Building Sustainability
Tina Patel Gunaldo, PhD, DPT, MHS; and Pamela Waynick-Rogers, DNP, APRN-BC
Sustainability Factors
Adaptability (Environment)
Acceptability (Social)
Affordability (Economic)
Emerging Research and Opportunities for Interprofessional Growth
Summary
Appendix: Additional Resources
Jordan Hamson-Utley, PhD, LAT, ATC, is the director of the postprofessional master of health science program and an associate professor at the University of St. Augustine for Health Sciences, where she presides as chairperson of the interprofessional education task force. Utley has practiced as a certified athletic trainer for 25 years across various settings and has 20 years of experience in health sciences education and academic leadership. She serves as a committee member of the National Athletic Trainers’ Association Post-Professional Education Committee (PPEC) and on the program planning committee for the American Interprofessional Health Collaborative (AIHC).
Utley was awarded Apple’s Distinguished Educator award in 2012 for innovative use of technology in health care education. She received the Excellence in Publishing Award from the University of Phoenix in 2014. In 2016, Utley was recognized for her collaboration and leadership at the University of St. Augustine when she accepted the Stanley Paris Award, the highest honor awarded by the board to university faculty members. In 2019, the National Athletic Trainers’ Association awarded her the International Speaker Grant to present on the impact of interprofessional education in health care.
Utley is a coauthor of the book Psychosocial Strategies for Athletic Training and continues to promote the evolving role of the athletic trainer on the health care team.
Cynthia Kay Mathena, PhD, OTR/L, is the dean of the College of Health Sciences at the University of St. Augustine for Health Sciences. Her responsibilities include oversight of programs with a focus on interprofessional education and innovative online delivery.
Mathena has over 30 years of experience as an occupational therapist and 25 years of higher education experience. She is active in state, local, and national professional organizations and serves on accreditation site visit teams as a chair. She has recently published on topics that include service learning and online education and has presented nationally on simulation and on approaches to interprofessional education. In her free time, she enjoys outdoor activities, fitness, and nutrition.
Tina Patel Gunaldo, PhD, DPT, MHS, is the director for the Center for Interprofessional Education and Collaborative Practice at Louisiana State University Health–New Orleans. In addition to presentations and publications, Dr. Gunaldo’s professional contributions include serving on the American Interprofessional Health Collaborative’s Scholarship Committee; on the Louisiana Immunization Workgroup, supporting a collaborative approach to increasing immunization rates; and on the American Physical Therapy Association’s Finance Committee. She contributes to the development of the Scholars Program for the Louisiana Area Health Education Center (AHEC). She is also the coeditor of the Health, Interprofessional Practice and Education journal.
"This book is highly recommended for anyone seeking a truly effective health care team to improve patient outcomes and minimize patient care errors. Well done!"
© Doody’s Review Service, 2020, Steven K Hamick, AAS, BIS, William Beaumont Hospitals, (5-star review)
Communication strategies for interprofessional teams
By Dee M. Lance and Kim C. McCullough
General Communication Strategies
The goal of interprofessional teams is to offer patients effective and efficient treatment, and communication is a factor that influences the ability to meet that goal. Klinzing and Klinzing11 have identified some internal and external forces that interfere with the ability to engage in conversations or meetings:
- The mind processes words faster than they can be spoken, which can result in the formulation of responses before the message has been delivered.
- As people try to multitask, they experience divided attention, which can interfere with the ability to sustain attention during meetings.
- Environmental distractors, such as cell phones, noise in the hall, and shuffling feet, can interrupt attention.
If we allow things to compete for our attention when we are in a meeting, then we stop being communication collaborators.
Communication is a complex process, and both speakers and listeners carry responsibility for success. We have identified 9 actions (modified from Seery)20 that can support interprofessional teams in their communication efforts.
1. Use Engaged Listening
We have all experienced talking to people and knowing they were not listening. The listeners may be physically distracted, checking their watch or looking at their phone. They may appear distracted, and it is evident they are thinking about something other than what you are saying.
Engaged listening is required for effective communication, and it involves actually hearing and trying to understand what the speaker intends for you to understand. When listening, you can gain clarification by asking questions or rephrasing what you are hearing so that you're sure you fully understand the message as intended. Lake and her colleagues6 remind us that listeners share responsibility for ensuring they have an accurate and complete understanding of the message. They suggest the following techniques for active listening:
- Resolve differences between verbal and nonverbal messages.
- Reflect your feelings about what is being said.
- Ask clarification questions.
- Restate the speaker's message.
Using these techniques helps make communication a process that is a partnership between speaker and listener.
2. Use Nonverbal Communication
As stated previously, the words we select for the sentences we say make up only 7% of the message being conveyed. For both speaker and listener, the conscious use of proxemics, kinesthetics, facial expression and eye behavior, and paralinguistics can reduce miscommunications. For example, your body language should help convey your words and should indicate your openness to the message being sent. Other nonverbal communication acts, such as standing or sitting (proxemics), hand gestures (kinesthetics), eye contact (facial expression and eye behavior), and voice tone (paralinguistics), can enhance communication. For example, a team member may be more likely to speak openly if you are relaxed, have a friendly tone, and use an open posture with uncrossed legs and arms. Eye contact is also important; too much can be intimidating and too little can indicate you are nervous or disengaged. Conscious use of nonverbal cues can help counteract some of the professional, cultural, and linguistic differences you are likely to encounter on interprofessional teams. You can also use your understanding of nonverbal cues to interpret how other team members are feeling.
3. Be Concise and Clear
Team members' time is important, so you should be as concise as possible. Understanding the purpose of your interaction can help you stay focused and convey only the relevant information, which in turn helps the team achieve its common goal efficiently. You should not sacrifice clarity for conciseness, however. Be mindful of shared meaning; group diversity (e.g., professional, cultural, dialectical) could make jargon, professional acronyms, and colloquialisms problematic. Failure to be both concise and clear can cause frustration and confusion.
4. Be Personable
Everyone likes to work with someone who is pleasant, agreeable, and kind. These are some of the characteristics that could be considered personable. Using both verbal and nonverbal communication can help convey information about yourself. This can be as simple as smiling and nodding when you agree with what is being said, managing your tone so that passion does not sound like aggression, allowing others to state their opinion first so that you appear receptive to other ideas, or adding a personal message to an email so that your communication is less abrupt.
5. Speak With Confidence
When you convey to other team members that you are up to the task, then effective communication can occur. If you sound tentative about your contribution to the team, the team will be cautious about your ability to help meet the goal. Using nonverbal cues such as tone and stance can help portray confidence. You should also listen to the message others are communicating and then use engaged listening to seek clarification.
6. Show Empathy
Empathy, the ability to take the perspective of another person or to understand what someone is feeling, is a foundational skill for successful interactions. You do not have to agree with what people are saying to show that you appreciate their perspective. By saying to your team members, “I understand where you are coming from,” you let them know that you have heard their message. Remember that people from low-context and high-context cultures will react differently to disagreements, so use other tools to ensure relationships among group members stay intact.
7. Stay Open-Minded
We have discussed cultural, dialectical, and gender differences, all of which can influence shared meaning, relationships, and decision making. Using all of your tools to project openness to others' opinions and ideas is necessary for honest and effective communication.
8. Give and Receive Feedback
When you ask for clarification or restate something that has been said, you are providing feedback about your understanding and potentially about the effectiveness of the interaction. This is an essential skill for communication and for the interprofessional team to be efficient and effective. There are other types of devices as well, such as praising someone's presentation or providing supportive, constructive feedback that can strengthen any team. How you give and receive feedback can affect team morale, so having a handle on the cultural differences within the group can help you frame your questions and feedback.
9. Consider the Medium
A large part of figuring out the medium (e.g., oral, written, electronic) for any communication is considering the audience and purpose. Remember, when contemplating a written format, only a small portion of any attempt to communicate is conveyed by the words selected. Sensitive information may best be handled in person. Some communication devices, such as humor and sarcasm, use paralinguistic features and can fall flat when using written language. Additionally, when selecting a communication medium, careful thought should be given to any content that is sensitive or confidential.
Lake and colleagues6 suggest that structured reflection is useful to monitor and increase self-awareness as you practice communication techniques within your interprofessional team. Self-reflection can take the form of journaling and checklists before or after meetings and interactions. Choosing good communication strategies, consciously using them in conversations and meetings, and evaluating both your successes and failures is important for your individual success as well as for doing your part to ensure that the interprofessional team is effective and efficient.
EBP of Teamship: Closed-Loop Communication
Closed-loop communication (CLC) is a well-known team communication technique that has been studied as a mechanism for providing feedback in health care settings when performing collaborative tasks. It is often used during medical procedures and is adaptable for other health care teams. CLC consists of 3 steps:
- A team member calls out an observation or message.
- The second team member confirms that the message was received.
- The first team member confirms that original message was understood correctly.
For example, during a team meeting, a nurse states that the patient is NPO. The PT on the team confirms that the patient cannot be given any food or liquids by mouth. The nurse confirms by stating, “That is correct, the patient cannot be given any food or drink even if the patient requests it.”
In a case study, Johnson and colleagues21 investigated CLC along with two other communication techniques, shared mental model (SMM) and mutual trust (MT). SMM is based on the notion that, over time, team members develop a common context that facilitates understanding and the prediction of outcomes. MT is based on the shared belief that team members will do what they are supposed to do and that their actions will protect the team. The authors found that CLC was most helpful to team communication when used in conjunction with SMM.
Collaborative Corner: Self-Reflection
You may want to start your self-reflection with the following types of questions:
- What message am I sending?
- Who am I trying to convince and why?
- Is the purpose of my communication to achieve a group goal or a personal one?
- Am I open to the other ideas presented?
- How do I want my message received, or how was my message received?
Barriers to professional and collaborative success
By Cindy Mathena
Just as enablers or opportunities have been outlined in the literature as being necessary for success, some barriers exist as well. Many are obvious and include professional cultures promoting silos or stereotypes, use of different language and terminology, accreditors, and a required prescribed curriculum.5,7 Students are educated as they always have been, in schools of nursing, colleges of social work, and departments of athletic training. One can walk into any hospital or medical facility and find that tribalism is still alive and well.13 Nurses are still holding nursing meetings, OTs still have their own department, and PTs are still working at their desks next to each other. This solo work commonly leads one to think of working in a silo. Socialization, communication, IPE, and IPCP are some of the more obvious solutions to this barrier.9,14
Collaboration by the health care team can come at a cost and is difficult to achieve in a hierarchical team where some are seen as the leaders (physicians) and others as the team. A large number of studies validate the presence of professional stereotypes and cultures in the health care workplace.9,13,14 Many argue the solution to silos rests on the shoulders of the educational institution. Learning environments must be created that encourage real-life scenarios where students can learn the complexities of communication and problem solving with other professionals and as a team.
Accreditation requirements can be another barrier, though it should be pointed out that accreditors are also in a position to enable IPE. In the same way we see health care professionals working in a silo, accrediting agencies that certify educational institutions and programs have also historically worked alone. Standards for accreditation are often so prescriptive that little room is left in the curriculum to explore the roles and language of other professionals. Several studies cite limitations in curricula focused on discipline-specific skills and knowledge as a barrier to IPE. Because curricula are often well defined by professional accreditors, integrating other professions and competencies can be challenging.10,15 If universities and institutions play a primary role in the integration of IPCP into the preparation of students in health care, accreditors may have the biggest opportunity to create impactful IPE. It has been suggested that this would include an intersection of accreditors with overlapping standards.
Accreditors occupy a unique position, working within and across professions and health care delivery settings to promote interprofessional collaboration in education and care. Those who work within individual health professions and those accreditors working in different health care delivery domains should look to cross professional and delivery divides for more integrated approaches to the evaluation and regulation of education and clinical practice.15(p2)
Inconsistent and varying terminologies have been recognized as a barrier to IPCP and IPE. In the authors' experience, we have encountered students across health care professions who claim this to be the most significant barrier to IPCP in the health care setting. And while the terminologies used by each discipline may widely vary, our students state that it is important to begin discussions about these differences in the classroom.
Separate to this conversation about terminology is the need to understand that the interpretation of IPCP and IPE may vary by discipline. One study found that nurses and physicians in the operating room defined collaboration very differently. Nurses interpreted it to mean influencing team decisions, whereas physicians interpreted it as meaning their directions would be followed by the other disciplines on the team.16
Additional barriers to IPE implementation were noted in a study of nursing and medical students' perceptions of enablers and barriers. Those barriers included varying knowledge levels, low mutual respect between professions, and capacity and legal issues.7
Create an effective health care team
By K. Michelle Knewstep-Watkins, C. Michelle Longley, and Meghan M. Scanlon
Interprofessional Team Composition
Creating a highly effective health care team is rarely as simple as assembling a group of providers who are knowledgeable and experienced in their clinical practice. Commonly, the group members who will become a health care team are diverse with regard to knowledge, experience, values, and expectations. These differences can present challenges in aligning the team toward a common purpose and accepted processes for meeting the goals.
In some cases, there is an established group of experienced health care providers who have been working together to meet patient needs. These providers may have worked this way for decades, shared many experiences, developed their professional identities in relation to one another, and developed long-standing meaningful friendships. It is critical to recognize that the group may be diverse in the number of years of experience and years working together, which can mean there are established roles, routines, and habits well beyond the simple norms of a scope of practice. However, this does not necessarily mean that these health care providers are a high-functioning team. Similarly, other groups may have a majority of entry-level providers or providers who are new to the group or to serving a particular population, but these characteristics do not necessarily imply that they are a poorly functioning team.
A health care team is effective when all team members understand their role as part of the team as well as the roles and areas of expertise of other team members. One's role on a health care team should not be dictated wholly by profession. For example, patient safety is not solely the responsibility or role of nurses; instead, it is recognized as a shared role. However, it is important to recognize the recommendation of a dietitian in the creation of a patient's nutritional intake, because the dietitian is the professional with the greatest content knowledge in this area, even if other providers have an understanding of nutrition. See chapter 4 for a review of the evidence highlighting the impact of years of experience on IPE and IPCP.
Collaborative workplace environments are routinely associated with improved patient outcomes due to effective workflows and synergistic relationships. Even with shared goals and collaborative relationships, such environments require intentionality. Conflict is an inevitable part of working in teams and stems from individual, contextual, and intrapersonal characteristics that can significantly impair team cohesion and objectives.10 It is important for team participants and leaders to be familiar with sources of group conflict and implement strategies to resolve conflict effectively.
It is also valuable to recognize that teaming in a health care organization occurs on many levels. A team is defined as a group of people who assemble to achieve a common goal, which can occur in any organization regardless of size or complexity. Thus, health care organizations are composed of many layers of teams. The organization as a whole is a team, and additional levels of health care teams are nested within the organization to address cascading goals of the central goal. A medical center may also have diagnosis-centered service areas, such as orthopedics, which are teams within the organization. Additionally, formal teams can assemble to meet a specific need, such as a patient education committee, or informal teams may emerge organically in order to collaborate and address a concern.
Collaborative Corner: Sources of Conflict
Conflict can arise from individual characteristics, contextual factors, or intrapersonal conditions.11
- Individual characteristics—Individual team members enter group settings from different backgrounds with individualized values, opinions, and experiences that lead to assumptions about patient care needs and how to meet them.
- Contextual factors—Situations in which roles and responsibilities are unclear or group goals lack clarity can cause stress and conflict, particularly when combined with fast-paced environments, unpredictability, or high-stakes outcomes.
- Intrapersonal conditions—Conflict is common in circumstances of actual or perceived hierarchical relationships, inconsistent team membership and participation, or limited member or group accountability.
What methods or activities might assist in identifying and addressing individual characteristics, contextual factors, and intrapersonal conditions that contribute to conflict?
Foundation of IPE teaching and learning
By Joy Doll, Anthony Breitbach, and Kathrin Eliot
Scanning the literature on IPE and IPCP quickly reveals that diversity and context dictate the methods of delivery, whether in the academic or clinical environment. IPE and IPCP are not delivered in a one-size-fits-all approach; rather, they challenge educators to consider the learning environment, learning outcomes, and delivery context. For example, in the case study at the beginning of the chapter, IPE was accomplished by faculty champions passionate about the approach, but a clear plan was not in place when institutional support for IPE expanded. However, examples of best practice exist at many academic and clinical institutions. Chapter 1 lends credibility to IPCP regarding benefits to systems, procedures, and health outcomes; however, there remains a gap in the research on how IPE should be implemented.10 Although the lack of a clear road map results in a challenging ambiguity, that same ambiguity offers extensive opportunity to innovate and engage in creative approaches to advance both IPE and IPCP.
As discussed by Masten and colleagues, the road map to IPE is more about implementing culture change than simply taking an educational approach.11 It requires leaders and educators to consider cultural context as a driver for the design and implementation of IPE, which has been presented as a best practice and a deliberate design approach.4Masten and colleagues describe these cultural changes following 5 stages (figure 2.2):
- Stage 1: Awakening—The process of recognizing the value and importance of IPE begins.
- Stage 2: Giving lip service—Leaders and educators move beyond talking about IPE to implementing structures to support it, like faculty time and reward.
- Stage 3: Parallel play—Pockets of IPE exist but are often not institutionalized.
- Stage 4: Group play—IPE curriculum advances, with administrators recognizing the challenges and faculty champions receiving support to move IPE forward.
- Stage 5: Cultural transformation—IPE is being implemented well and is recognized by the wider university.11
Figure 2.2 Stages of IPE development.
This approach provides a road map for the stages of cultural transformation necessary to make IPE a sustained reality (for more on sustainability, see chapter 8). Despite the lack of clear evidence for an ideal IPE curriculum, the literature on teamwork and team science provides extensive support to pedagogical approaches. The reality remains that attitudes, behaviors, and skills that elicit successful IPCP do not require a clear end point of accomplishment or competence; rather, they require educators to prepare students for an ambiguous and unclear journey.13 This chapter provides a foundation to prepare learners (e.g., students, residents, fellows, clinicians, faculty) to gain the attitudes, behaviors, and skills to negotiate the contemporary health care landscape that is keenly focused on population health and societal needs.
Health care is a team sport
By Jordan Hamson-Utley
Health care is a team sport. Just as sport requires athleticism and sport-specific skills operating in synergy toward a goal, health care teams require captains, diverse skill sets, and coordination to improve a patient's health. In basketball, could a team of only point guards beat a championship team? This might be the health care equivalent of a team of only PTs providing care for a patient after a stroke, for example. Additionally, IPCP is essential for health care teams to achieve patient care goals. Each position on a team requires a unique set of skills; without a point guard, a basketball team would lack leadership, ball vision, communication, and a 3-point scoring threat. Similarly, without a case lead, a care team would lack leadership, planning, communication, and an opportunity to win by providing the best patient care possible.
Graduating team-ready health care professionals requires seasoned educators, those who are experts in best practices not only in the classroom but also in IPE facilitation. As a result of limited experience in IPE facilitation, many educators are slowing the adoption of IPE1 and potentially limiting the capacity of graduates to be ready to practice in a contemporary workplace. Literature to date is limited (but growing) in the area of faculty development for IPE, and existing research is not adequate to consider any method a best practice.2 However, promising findings across existing methodologies indicate the value of modeling IPE knowledge, skills, and attitudes (KSAs); group work; reflection; and appreciation of diversity.1
Educator development is a critical component in the effective delivery of IPE. For an interprofessional team to achieve its purpose, it must capitalize on the diverse knowledge and skills of the team. Delivering educator training in a collaborative framework affords exposure to teammates that promotes learning about each other, from each other, and with each other to devise strategies and solve problems related to classroom delivery or team-based patient care. The literature has established that continuing education that isolates health care professions prevents clinicians from developing collaborative capacities that meet the challenges of today's workplace.3,4 Programs that deliver learning using a teaming approach are best positioned to benefit from the role models and networks that are built into this approach. Faculty and clinicians who are expected to engage in IPE and the team-based learning of future clinicians must be supported with the knowledge and skills necessary to design and facilitate IPE.5
Communication strategies for interprofessional teams
By Dee M. Lance and Kim C. McCullough
General Communication Strategies
The goal of interprofessional teams is to offer patients effective and efficient treatment, and communication is a factor that influences the ability to meet that goal. Klinzing and Klinzing11 have identified some internal and external forces that interfere with the ability to engage in conversations or meetings:
- The mind processes words faster than they can be spoken, which can result in the formulation of responses before the message has been delivered.
- As people try to multitask, they experience divided attention, which can interfere with the ability to sustain attention during meetings.
- Environmental distractors, such as cell phones, noise in the hall, and shuffling feet, can interrupt attention.
If we allow things to compete for our attention when we are in a meeting, then we stop being communication collaborators.
Communication is a complex process, and both speakers and listeners carry responsibility for success. We have identified 9 actions (modified from Seery)20 that can support interprofessional teams in their communication efforts.
1. Use Engaged Listening
We have all experienced talking to people and knowing they were not listening. The listeners may be physically distracted, checking their watch or looking at their phone. They may appear distracted, and it is evident they are thinking about something other than what you are saying.
Engaged listening is required for effective communication, and it involves actually hearing and trying to understand what the speaker intends for you to understand. When listening, you can gain clarification by asking questions or rephrasing what you are hearing so that you're sure you fully understand the message as intended. Lake and her colleagues6 remind us that listeners share responsibility for ensuring they have an accurate and complete understanding of the message. They suggest the following techniques for active listening:
- Resolve differences between verbal and nonverbal messages.
- Reflect your feelings about what is being said.
- Ask clarification questions.
- Restate the speaker's message.
Using these techniques helps make communication a process that is a partnership between speaker and listener.
2. Use Nonverbal Communication
As stated previously, the words we select for the sentences we say make up only 7% of the message being conveyed. For both speaker and listener, the conscious use of proxemics, kinesthetics, facial expression and eye behavior, and paralinguistics can reduce miscommunications. For example, your body language should help convey your words and should indicate your openness to the message being sent. Other nonverbal communication acts, such as standing or sitting (proxemics), hand gestures (kinesthetics), eye contact (facial expression and eye behavior), and voice tone (paralinguistics), can enhance communication. For example, a team member may be more likely to speak openly if you are relaxed, have a friendly tone, and use an open posture with uncrossed legs and arms. Eye contact is also important; too much can be intimidating and too little can indicate you are nervous or disengaged. Conscious use of nonverbal cues can help counteract some of the professional, cultural, and linguistic differences you are likely to encounter on interprofessional teams. You can also use your understanding of nonverbal cues to interpret how other team members are feeling.
3. Be Concise and Clear
Team members' time is important, so you should be as concise as possible. Understanding the purpose of your interaction can help you stay focused and convey only the relevant information, which in turn helps the team achieve its common goal efficiently. You should not sacrifice clarity for conciseness, however. Be mindful of shared meaning; group diversity (e.g., professional, cultural, dialectical) could make jargon, professional acronyms, and colloquialisms problematic. Failure to be both concise and clear can cause frustration and confusion.
4. Be Personable
Everyone likes to work with someone who is pleasant, agreeable, and kind. These are some of the characteristics that could be considered personable. Using both verbal and nonverbal communication can help convey information about yourself. This can be as simple as smiling and nodding when you agree with what is being said, managing your tone so that passion does not sound like aggression, allowing others to state their opinion first so that you appear receptive to other ideas, or adding a personal message to an email so that your communication is less abrupt.
5. Speak With Confidence
When you convey to other team members that you are up to the task, then effective communication can occur. If you sound tentative about your contribution to the team, the team will be cautious about your ability to help meet the goal. Using nonverbal cues such as tone and stance can help portray confidence. You should also listen to the message others are communicating and then use engaged listening to seek clarification.
6. Show Empathy
Empathy, the ability to take the perspective of another person or to understand what someone is feeling, is a foundational skill for successful interactions. You do not have to agree with what people are saying to show that you appreciate their perspective. By saying to your team members, “I understand where you are coming from,” you let them know that you have heard their message. Remember that people from low-context and high-context cultures will react differently to disagreements, so use other tools to ensure relationships among group members stay intact.
7. Stay Open-Minded
We have discussed cultural, dialectical, and gender differences, all of which can influence shared meaning, relationships, and decision making. Using all of your tools to project openness to others' opinions and ideas is necessary for honest and effective communication.
8. Give and Receive Feedback
When you ask for clarification or restate something that has been said, you are providing feedback about your understanding and potentially about the effectiveness of the interaction. This is an essential skill for communication and for the interprofessional team to be efficient and effective. There are other types of devices as well, such as praising someone's presentation or providing supportive, constructive feedback that can strengthen any team. How you give and receive feedback can affect team morale, so having a handle on the cultural differences within the group can help you frame your questions and feedback.
9. Consider the Medium
A large part of figuring out the medium (e.g., oral, written, electronic) for any communication is considering the audience and purpose. Remember, when contemplating a written format, only a small portion of any attempt to communicate is conveyed by the words selected. Sensitive information may best be handled in person. Some communication devices, such as humor and sarcasm, use paralinguistic features and can fall flat when using written language. Additionally, when selecting a communication medium, careful thought should be given to any content that is sensitive or confidential.
Lake and colleagues6 suggest that structured reflection is useful to monitor and increase self-awareness as you practice communication techniques within your interprofessional team. Self-reflection can take the form of journaling and checklists before or after meetings and interactions. Choosing good communication strategies, consciously using them in conversations and meetings, and evaluating both your successes and failures is important for your individual success as well as for doing your part to ensure that the interprofessional team is effective and efficient.
EBP of Teamship: Closed-Loop Communication
Closed-loop communication (CLC) is a well-known team communication technique that has been studied as a mechanism for providing feedback in health care settings when performing collaborative tasks. It is often used during medical procedures and is adaptable for other health care teams. CLC consists of 3 steps:
- A team member calls out an observation or message.
- The second team member confirms that the message was received.
- The first team member confirms that original message was understood correctly.
For example, during a team meeting, a nurse states that the patient is NPO. The PT on the team confirms that the patient cannot be given any food or liquids by mouth. The nurse confirms by stating, “That is correct, the patient cannot be given any food or drink even if the patient requests it.”
In a case study, Johnson and colleagues21 investigated CLC along with two other communication techniques, shared mental model (SMM) and mutual trust (MT). SMM is based on the notion that, over time, team members develop a common context that facilitates understanding and the prediction of outcomes. MT is based on the shared belief that team members will do what they are supposed to do and that their actions will protect the team. The authors found that CLC was most helpful to team communication when used in conjunction with SMM.
Collaborative Corner: Self-Reflection
You may want to start your self-reflection with the following types of questions:
- What message am I sending?
- Who am I trying to convince and why?
- Is the purpose of my communication to achieve a group goal or a personal one?
- Am I open to the other ideas presented?
- How do I want my message received, or how was my message received?
Barriers to professional and collaborative success
By Cindy Mathena
Just as enablers or opportunities have been outlined in the literature as being necessary for success, some barriers exist as well. Many are obvious and include professional cultures promoting silos or stereotypes, use of different language and terminology, accreditors, and a required prescribed curriculum.5,7 Students are educated as they always have been, in schools of nursing, colleges of social work, and departments of athletic training. One can walk into any hospital or medical facility and find that tribalism is still alive and well.13 Nurses are still holding nursing meetings, OTs still have their own department, and PTs are still working at their desks next to each other. This solo work commonly leads one to think of working in a silo. Socialization, communication, IPE, and IPCP are some of the more obvious solutions to this barrier.9,14
Collaboration by the health care team can come at a cost and is difficult to achieve in a hierarchical team where some are seen as the leaders (physicians) and others as the team. A large number of studies validate the presence of professional stereotypes and cultures in the health care workplace.9,13,14 Many argue the solution to silos rests on the shoulders of the educational institution. Learning environments must be created that encourage real-life scenarios where students can learn the complexities of communication and problem solving with other professionals and as a team.
Accreditation requirements can be another barrier, though it should be pointed out that accreditors are also in a position to enable IPE. In the same way we see health care professionals working in a silo, accrediting agencies that certify educational institutions and programs have also historically worked alone. Standards for accreditation are often so prescriptive that little room is left in the curriculum to explore the roles and language of other professionals. Several studies cite limitations in curricula focused on discipline-specific skills and knowledge as a barrier to IPE. Because curricula are often well defined by professional accreditors, integrating other professions and competencies can be challenging.10,15 If universities and institutions play a primary role in the integration of IPCP into the preparation of students in health care, accreditors may have the biggest opportunity to create impactful IPE. It has been suggested that this would include an intersection of accreditors with overlapping standards.
Accreditors occupy a unique position, working within and across professions and health care delivery settings to promote interprofessional collaboration in education and care. Those who work within individual health professions and those accreditors working in different health care delivery domains should look to cross professional and delivery divides for more integrated approaches to the evaluation and regulation of education and clinical practice.15(p2)
Inconsistent and varying terminologies have been recognized as a barrier to IPCP and IPE. In the authors' experience, we have encountered students across health care professions who claim this to be the most significant barrier to IPCP in the health care setting. And while the terminologies used by each discipline may widely vary, our students state that it is important to begin discussions about these differences in the classroom.
Separate to this conversation about terminology is the need to understand that the interpretation of IPCP and IPE may vary by discipline. One study found that nurses and physicians in the operating room defined collaboration very differently. Nurses interpreted it to mean influencing team decisions, whereas physicians interpreted it as meaning their directions would be followed by the other disciplines on the team.16
Additional barriers to IPE implementation were noted in a study of nursing and medical students' perceptions of enablers and barriers. Those barriers included varying knowledge levels, low mutual respect between professions, and capacity and legal issues.7
Create an effective health care team
By K. Michelle Knewstep-Watkins, C. Michelle Longley, and Meghan M. Scanlon
Interprofessional Team Composition
Creating a highly effective health care team is rarely as simple as assembling a group of providers who are knowledgeable and experienced in their clinical practice. Commonly, the group members who will become a health care team are diverse with regard to knowledge, experience, values, and expectations. These differences can present challenges in aligning the team toward a common purpose and accepted processes for meeting the goals.
In some cases, there is an established group of experienced health care providers who have been working together to meet patient needs. These providers may have worked this way for decades, shared many experiences, developed their professional identities in relation to one another, and developed long-standing meaningful friendships. It is critical to recognize that the group may be diverse in the number of years of experience and years working together, which can mean there are established roles, routines, and habits well beyond the simple norms of a scope of practice. However, this does not necessarily mean that these health care providers are a high-functioning team. Similarly, other groups may have a majority of entry-level providers or providers who are new to the group or to serving a particular population, but these characteristics do not necessarily imply that they are a poorly functioning team.
A health care team is effective when all team members understand their role as part of the team as well as the roles and areas of expertise of other team members. One's role on a health care team should not be dictated wholly by profession. For example, patient safety is not solely the responsibility or role of nurses; instead, it is recognized as a shared role. However, it is important to recognize the recommendation of a dietitian in the creation of a patient's nutritional intake, because the dietitian is the professional with the greatest content knowledge in this area, even if other providers have an understanding of nutrition. See chapter 4 for a review of the evidence highlighting the impact of years of experience on IPE and IPCP.
Collaborative workplace environments are routinely associated with improved patient outcomes due to effective workflows and synergistic relationships. Even with shared goals and collaborative relationships, such environments require intentionality. Conflict is an inevitable part of working in teams and stems from individual, contextual, and intrapersonal characteristics that can significantly impair team cohesion and objectives.10 It is important for team participants and leaders to be familiar with sources of group conflict and implement strategies to resolve conflict effectively.
It is also valuable to recognize that teaming in a health care organization occurs on many levels. A team is defined as a group of people who assemble to achieve a common goal, which can occur in any organization regardless of size or complexity. Thus, health care organizations are composed of many layers of teams. The organization as a whole is a team, and additional levels of health care teams are nested within the organization to address cascading goals of the central goal. A medical center may also have diagnosis-centered service areas, such as orthopedics, which are teams within the organization. Additionally, formal teams can assemble to meet a specific need, such as a patient education committee, or informal teams may emerge organically in order to collaborate and address a concern.
Collaborative Corner: Sources of Conflict
Conflict can arise from individual characteristics, contextual factors, or intrapersonal conditions.11
- Individual characteristics—Individual team members enter group settings from different backgrounds with individualized values, opinions, and experiences that lead to assumptions about patient care needs and how to meet them.
- Contextual factors—Situations in which roles and responsibilities are unclear or group goals lack clarity can cause stress and conflict, particularly when combined with fast-paced environments, unpredictability, or high-stakes outcomes.
- Intrapersonal conditions—Conflict is common in circumstances of actual or perceived hierarchical relationships, inconsistent team membership and participation, or limited member or group accountability.
What methods or activities might assist in identifying and addressing individual characteristics, contextual factors, and intrapersonal conditions that contribute to conflict?
Foundation of IPE teaching and learning
By Joy Doll, Anthony Breitbach, and Kathrin Eliot
Scanning the literature on IPE and IPCP quickly reveals that diversity and context dictate the methods of delivery, whether in the academic or clinical environment. IPE and IPCP are not delivered in a one-size-fits-all approach; rather, they challenge educators to consider the learning environment, learning outcomes, and delivery context. For example, in the case study at the beginning of the chapter, IPE was accomplished by faculty champions passionate about the approach, but a clear plan was not in place when institutional support for IPE expanded. However, examples of best practice exist at many academic and clinical institutions. Chapter 1 lends credibility to IPCP regarding benefits to systems, procedures, and health outcomes; however, there remains a gap in the research on how IPE should be implemented.10 Although the lack of a clear road map results in a challenging ambiguity, that same ambiguity offers extensive opportunity to innovate and engage in creative approaches to advance both IPE and IPCP.
As discussed by Masten and colleagues, the road map to IPE is more about implementing culture change than simply taking an educational approach.11 It requires leaders and educators to consider cultural context as a driver for the design and implementation of IPE, which has been presented as a best practice and a deliberate design approach.4Masten and colleagues describe these cultural changes following 5 stages (figure 2.2):
- Stage 1: Awakening—The process of recognizing the value and importance of IPE begins.
- Stage 2: Giving lip service—Leaders and educators move beyond talking about IPE to implementing structures to support it, like faculty time and reward.
- Stage 3: Parallel play—Pockets of IPE exist but are often not institutionalized.
- Stage 4: Group play—IPE curriculum advances, with administrators recognizing the challenges and faculty champions receiving support to move IPE forward.
- Stage 5: Cultural transformation—IPE is being implemented well and is recognized by the wider university.11
Figure 2.2 Stages of IPE development.
This approach provides a road map for the stages of cultural transformation necessary to make IPE a sustained reality (for more on sustainability, see chapter 8). Despite the lack of clear evidence for an ideal IPE curriculum, the literature on teamwork and team science provides extensive support to pedagogical approaches. The reality remains that attitudes, behaviors, and skills that elicit successful IPCP do not require a clear end point of accomplishment or competence; rather, they require educators to prepare students for an ambiguous and unclear journey.13 This chapter provides a foundation to prepare learners (e.g., students, residents, fellows, clinicians, faculty) to gain the attitudes, behaviors, and skills to negotiate the contemporary health care landscape that is keenly focused on population health and societal needs.
Health care is a team sport
By Jordan Hamson-Utley
Health care is a team sport. Just as sport requires athleticism and sport-specific skills operating in synergy toward a goal, health care teams require captains, diverse skill sets, and coordination to improve a patient's health. In basketball, could a team of only point guards beat a championship team? This might be the health care equivalent of a team of only PTs providing care for a patient after a stroke, for example. Additionally, IPCP is essential for health care teams to achieve patient care goals. Each position on a team requires a unique set of skills; without a point guard, a basketball team would lack leadership, ball vision, communication, and a 3-point scoring threat. Similarly, without a case lead, a care team would lack leadership, planning, communication, and an opportunity to win by providing the best patient care possible.
Graduating team-ready health care professionals requires seasoned educators, those who are experts in best practices not only in the classroom but also in IPE facilitation. As a result of limited experience in IPE facilitation, many educators are slowing the adoption of IPE1 and potentially limiting the capacity of graduates to be ready to practice in a contemporary workplace. Literature to date is limited (but growing) in the area of faculty development for IPE, and existing research is not adequate to consider any method a best practice.2 However, promising findings across existing methodologies indicate the value of modeling IPE knowledge, skills, and attitudes (KSAs); group work; reflection; and appreciation of diversity.1
Educator development is a critical component in the effective delivery of IPE. For an interprofessional team to achieve its purpose, it must capitalize on the diverse knowledge and skills of the team. Delivering educator training in a collaborative framework affords exposure to teammates that promotes learning about each other, from each other, and with each other to devise strategies and solve problems related to classroom delivery or team-based patient care. The literature has established that continuing education that isolates health care professions prevents clinicians from developing collaborative capacities that meet the challenges of today's workplace.3,4 Programs that deliver learning using a teaming approach are best positioned to benefit from the role models and networks that are built into this approach. Faculty and clinicians who are expected to engage in IPE and the team-based learning of future clinicians must be supported with the knowledge and skills necessary to design and facilitate IPE.5
Communication strategies for interprofessional teams
By Dee M. Lance and Kim C. McCullough
General Communication Strategies
The goal of interprofessional teams is to offer patients effective and efficient treatment, and communication is a factor that influences the ability to meet that goal. Klinzing and Klinzing11 have identified some internal and external forces that interfere with the ability to engage in conversations or meetings:
- The mind processes words faster than they can be spoken, which can result in the formulation of responses before the message has been delivered.
- As people try to multitask, they experience divided attention, which can interfere with the ability to sustain attention during meetings.
- Environmental distractors, such as cell phones, noise in the hall, and shuffling feet, can interrupt attention.
If we allow things to compete for our attention when we are in a meeting, then we stop being communication collaborators.
Communication is a complex process, and both speakers and listeners carry responsibility for success. We have identified 9 actions (modified from Seery)20 that can support interprofessional teams in their communication efforts.
1. Use Engaged Listening
We have all experienced talking to people and knowing they were not listening. The listeners may be physically distracted, checking their watch or looking at their phone. They may appear distracted, and it is evident they are thinking about something other than what you are saying.
Engaged listening is required for effective communication, and it involves actually hearing and trying to understand what the speaker intends for you to understand. When listening, you can gain clarification by asking questions or rephrasing what you are hearing so that you're sure you fully understand the message as intended. Lake and her colleagues6 remind us that listeners share responsibility for ensuring they have an accurate and complete understanding of the message. They suggest the following techniques for active listening:
- Resolve differences between verbal and nonverbal messages.
- Reflect your feelings about what is being said.
- Ask clarification questions.
- Restate the speaker's message.
Using these techniques helps make communication a process that is a partnership between speaker and listener.
2. Use Nonverbal Communication
As stated previously, the words we select for the sentences we say make up only 7% of the message being conveyed. For both speaker and listener, the conscious use of proxemics, kinesthetics, facial expression and eye behavior, and paralinguistics can reduce miscommunications. For example, your body language should help convey your words and should indicate your openness to the message being sent. Other nonverbal communication acts, such as standing or sitting (proxemics), hand gestures (kinesthetics), eye contact (facial expression and eye behavior), and voice tone (paralinguistics), can enhance communication. For example, a team member may be more likely to speak openly if you are relaxed, have a friendly tone, and use an open posture with uncrossed legs and arms. Eye contact is also important; too much can be intimidating and too little can indicate you are nervous or disengaged. Conscious use of nonverbal cues can help counteract some of the professional, cultural, and linguistic differences you are likely to encounter on interprofessional teams. You can also use your understanding of nonverbal cues to interpret how other team members are feeling.
3. Be Concise and Clear
Team members' time is important, so you should be as concise as possible. Understanding the purpose of your interaction can help you stay focused and convey only the relevant information, which in turn helps the team achieve its common goal efficiently. You should not sacrifice clarity for conciseness, however. Be mindful of shared meaning; group diversity (e.g., professional, cultural, dialectical) could make jargon, professional acronyms, and colloquialisms problematic. Failure to be both concise and clear can cause frustration and confusion.
4. Be Personable
Everyone likes to work with someone who is pleasant, agreeable, and kind. These are some of the characteristics that could be considered personable. Using both verbal and nonverbal communication can help convey information about yourself. This can be as simple as smiling and nodding when you agree with what is being said, managing your tone so that passion does not sound like aggression, allowing others to state their opinion first so that you appear receptive to other ideas, or adding a personal message to an email so that your communication is less abrupt.
5. Speak With Confidence
When you convey to other team members that you are up to the task, then effective communication can occur. If you sound tentative about your contribution to the team, the team will be cautious about your ability to help meet the goal. Using nonverbal cues such as tone and stance can help portray confidence. You should also listen to the message others are communicating and then use engaged listening to seek clarification.
6. Show Empathy
Empathy, the ability to take the perspective of another person or to understand what someone is feeling, is a foundational skill for successful interactions. You do not have to agree with what people are saying to show that you appreciate their perspective. By saying to your team members, “I understand where you are coming from,” you let them know that you have heard their message. Remember that people from low-context and high-context cultures will react differently to disagreements, so use other tools to ensure relationships among group members stay intact.
7. Stay Open-Minded
We have discussed cultural, dialectical, and gender differences, all of which can influence shared meaning, relationships, and decision making. Using all of your tools to project openness to others' opinions and ideas is necessary for honest and effective communication.
8. Give and Receive Feedback
When you ask for clarification or restate something that has been said, you are providing feedback about your understanding and potentially about the effectiveness of the interaction. This is an essential skill for communication and for the interprofessional team to be efficient and effective. There are other types of devices as well, such as praising someone's presentation or providing supportive, constructive feedback that can strengthen any team. How you give and receive feedback can affect team morale, so having a handle on the cultural differences within the group can help you frame your questions and feedback.
9. Consider the Medium
A large part of figuring out the medium (e.g., oral, written, electronic) for any communication is considering the audience and purpose. Remember, when contemplating a written format, only a small portion of any attempt to communicate is conveyed by the words selected. Sensitive information may best be handled in person. Some communication devices, such as humor and sarcasm, use paralinguistic features and can fall flat when using written language. Additionally, when selecting a communication medium, careful thought should be given to any content that is sensitive or confidential.
Lake and colleagues6 suggest that structured reflection is useful to monitor and increase self-awareness as you practice communication techniques within your interprofessional team. Self-reflection can take the form of journaling and checklists before or after meetings and interactions. Choosing good communication strategies, consciously using them in conversations and meetings, and evaluating both your successes and failures is important for your individual success as well as for doing your part to ensure that the interprofessional team is effective and efficient.
EBP of Teamship: Closed-Loop Communication
Closed-loop communication (CLC) is a well-known team communication technique that has been studied as a mechanism for providing feedback in health care settings when performing collaborative tasks. It is often used during medical procedures and is adaptable for other health care teams. CLC consists of 3 steps:
- A team member calls out an observation or message.
- The second team member confirms that the message was received.
- The first team member confirms that original message was understood correctly.
For example, during a team meeting, a nurse states that the patient is NPO. The PT on the team confirms that the patient cannot be given any food or liquids by mouth. The nurse confirms by stating, “That is correct, the patient cannot be given any food or drink even if the patient requests it.”
In a case study, Johnson and colleagues21 investigated CLC along with two other communication techniques, shared mental model (SMM) and mutual trust (MT). SMM is based on the notion that, over time, team members develop a common context that facilitates understanding and the prediction of outcomes. MT is based on the shared belief that team members will do what they are supposed to do and that their actions will protect the team. The authors found that CLC was most helpful to team communication when used in conjunction with SMM.
Collaborative Corner: Self-Reflection
You may want to start your self-reflection with the following types of questions:
- What message am I sending?
- Who am I trying to convince and why?
- Is the purpose of my communication to achieve a group goal or a personal one?
- Am I open to the other ideas presented?
- How do I want my message received, or how was my message received?
Barriers to professional and collaborative success
By Cindy Mathena
Just as enablers or opportunities have been outlined in the literature as being necessary for success, some barriers exist as well. Many are obvious and include professional cultures promoting silos or stereotypes, use of different language and terminology, accreditors, and a required prescribed curriculum.5,7 Students are educated as they always have been, in schools of nursing, colleges of social work, and departments of athletic training. One can walk into any hospital or medical facility and find that tribalism is still alive and well.13 Nurses are still holding nursing meetings, OTs still have their own department, and PTs are still working at their desks next to each other. This solo work commonly leads one to think of working in a silo. Socialization, communication, IPE, and IPCP are some of the more obvious solutions to this barrier.9,14
Collaboration by the health care team can come at a cost and is difficult to achieve in a hierarchical team where some are seen as the leaders (physicians) and others as the team. A large number of studies validate the presence of professional stereotypes and cultures in the health care workplace.9,13,14 Many argue the solution to silos rests on the shoulders of the educational institution. Learning environments must be created that encourage real-life scenarios where students can learn the complexities of communication and problem solving with other professionals and as a team.
Accreditation requirements can be another barrier, though it should be pointed out that accreditors are also in a position to enable IPE. In the same way we see health care professionals working in a silo, accrediting agencies that certify educational institutions and programs have also historically worked alone. Standards for accreditation are often so prescriptive that little room is left in the curriculum to explore the roles and language of other professionals. Several studies cite limitations in curricula focused on discipline-specific skills and knowledge as a barrier to IPE. Because curricula are often well defined by professional accreditors, integrating other professions and competencies can be challenging.10,15 If universities and institutions play a primary role in the integration of IPCP into the preparation of students in health care, accreditors may have the biggest opportunity to create impactful IPE. It has been suggested that this would include an intersection of accreditors with overlapping standards.
Accreditors occupy a unique position, working within and across professions and health care delivery settings to promote interprofessional collaboration in education and care. Those who work within individual health professions and those accreditors working in different health care delivery domains should look to cross professional and delivery divides for more integrated approaches to the evaluation and regulation of education and clinical practice.15(p2)
Inconsistent and varying terminologies have been recognized as a barrier to IPCP and IPE. In the authors' experience, we have encountered students across health care professions who claim this to be the most significant barrier to IPCP in the health care setting. And while the terminologies used by each discipline may widely vary, our students state that it is important to begin discussions about these differences in the classroom.
Separate to this conversation about terminology is the need to understand that the interpretation of IPCP and IPE may vary by discipline. One study found that nurses and physicians in the operating room defined collaboration very differently. Nurses interpreted it to mean influencing team decisions, whereas physicians interpreted it as meaning their directions would be followed by the other disciplines on the team.16
Additional barriers to IPE implementation were noted in a study of nursing and medical students' perceptions of enablers and barriers. Those barriers included varying knowledge levels, low mutual respect between professions, and capacity and legal issues.7
Create an effective health care team
By K. Michelle Knewstep-Watkins, C. Michelle Longley, and Meghan M. Scanlon
Interprofessional Team Composition
Creating a highly effective health care team is rarely as simple as assembling a group of providers who are knowledgeable and experienced in their clinical practice. Commonly, the group members who will become a health care team are diverse with regard to knowledge, experience, values, and expectations. These differences can present challenges in aligning the team toward a common purpose and accepted processes for meeting the goals.
In some cases, there is an established group of experienced health care providers who have been working together to meet patient needs. These providers may have worked this way for decades, shared many experiences, developed their professional identities in relation to one another, and developed long-standing meaningful friendships. It is critical to recognize that the group may be diverse in the number of years of experience and years working together, which can mean there are established roles, routines, and habits well beyond the simple norms of a scope of practice. However, this does not necessarily mean that these health care providers are a high-functioning team. Similarly, other groups may have a majority of entry-level providers or providers who are new to the group or to serving a particular population, but these characteristics do not necessarily imply that they are a poorly functioning team.
A health care team is effective when all team members understand their role as part of the team as well as the roles and areas of expertise of other team members. One's role on a health care team should not be dictated wholly by profession. For example, patient safety is not solely the responsibility or role of nurses; instead, it is recognized as a shared role. However, it is important to recognize the recommendation of a dietitian in the creation of a patient's nutritional intake, because the dietitian is the professional with the greatest content knowledge in this area, even if other providers have an understanding of nutrition. See chapter 4 for a review of the evidence highlighting the impact of years of experience on IPE and IPCP.
Collaborative workplace environments are routinely associated with improved patient outcomes due to effective workflows and synergistic relationships. Even with shared goals and collaborative relationships, such environments require intentionality. Conflict is an inevitable part of working in teams and stems from individual, contextual, and intrapersonal characteristics that can significantly impair team cohesion and objectives.10 It is important for team participants and leaders to be familiar with sources of group conflict and implement strategies to resolve conflict effectively.
It is also valuable to recognize that teaming in a health care organization occurs on many levels. A team is defined as a group of people who assemble to achieve a common goal, which can occur in any organization regardless of size or complexity. Thus, health care organizations are composed of many layers of teams. The organization as a whole is a team, and additional levels of health care teams are nested within the organization to address cascading goals of the central goal. A medical center may also have diagnosis-centered service areas, such as orthopedics, which are teams within the organization. Additionally, formal teams can assemble to meet a specific need, such as a patient education committee, or informal teams may emerge organically in order to collaborate and address a concern.
Collaborative Corner: Sources of Conflict
Conflict can arise from individual characteristics, contextual factors, or intrapersonal conditions.11
- Individual characteristics—Individual team members enter group settings from different backgrounds with individualized values, opinions, and experiences that lead to assumptions about patient care needs and how to meet them.
- Contextual factors—Situations in which roles and responsibilities are unclear or group goals lack clarity can cause stress and conflict, particularly when combined with fast-paced environments, unpredictability, or high-stakes outcomes.
- Intrapersonal conditions—Conflict is common in circumstances of actual or perceived hierarchical relationships, inconsistent team membership and participation, or limited member or group accountability.
What methods or activities might assist in identifying and addressing individual characteristics, contextual factors, and intrapersonal conditions that contribute to conflict?
Foundation of IPE teaching and learning
By Joy Doll, Anthony Breitbach, and Kathrin Eliot
Scanning the literature on IPE and IPCP quickly reveals that diversity and context dictate the methods of delivery, whether in the academic or clinical environment. IPE and IPCP are not delivered in a one-size-fits-all approach; rather, they challenge educators to consider the learning environment, learning outcomes, and delivery context. For example, in the case study at the beginning of the chapter, IPE was accomplished by faculty champions passionate about the approach, but a clear plan was not in place when institutional support for IPE expanded. However, examples of best practice exist at many academic and clinical institutions. Chapter 1 lends credibility to IPCP regarding benefits to systems, procedures, and health outcomes; however, there remains a gap in the research on how IPE should be implemented.10 Although the lack of a clear road map results in a challenging ambiguity, that same ambiguity offers extensive opportunity to innovate and engage in creative approaches to advance both IPE and IPCP.
As discussed by Masten and colleagues, the road map to IPE is more about implementing culture change than simply taking an educational approach.11 It requires leaders and educators to consider cultural context as a driver for the design and implementation of IPE, which has been presented as a best practice and a deliberate design approach.4Masten and colleagues describe these cultural changes following 5 stages (figure 2.2):
- Stage 1: Awakening—The process of recognizing the value and importance of IPE begins.
- Stage 2: Giving lip service—Leaders and educators move beyond talking about IPE to implementing structures to support it, like faculty time and reward.
- Stage 3: Parallel play—Pockets of IPE exist but are often not institutionalized.
- Stage 4: Group play—IPE curriculum advances, with administrators recognizing the challenges and faculty champions receiving support to move IPE forward.
- Stage 5: Cultural transformation—IPE is being implemented well and is recognized by the wider university.11
Figure 2.2 Stages of IPE development.
This approach provides a road map for the stages of cultural transformation necessary to make IPE a sustained reality (for more on sustainability, see chapter 8). Despite the lack of clear evidence for an ideal IPE curriculum, the literature on teamwork and team science provides extensive support to pedagogical approaches. The reality remains that attitudes, behaviors, and skills that elicit successful IPCP do not require a clear end point of accomplishment or competence; rather, they require educators to prepare students for an ambiguous and unclear journey.13 This chapter provides a foundation to prepare learners (e.g., students, residents, fellows, clinicians, faculty) to gain the attitudes, behaviors, and skills to negotiate the contemporary health care landscape that is keenly focused on population health and societal needs.
Health care is a team sport
By Jordan Hamson-Utley
Health care is a team sport. Just as sport requires athleticism and sport-specific skills operating in synergy toward a goal, health care teams require captains, diverse skill sets, and coordination to improve a patient's health. In basketball, could a team of only point guards beat a championship team? This might be the health care equivalent of a team of only PTs providing care for a patient after a stroke, for example. Additionally, IPCP is essential for health care teams to achieve patient care goals. Each position on a team requires a unique set of skills; without a point guard, a basketball team would lack leadership, ball vision, communication, and a 3-point scoring threat. Similarly, without a case lead, a care team would lack leadership, planning, communication, and an opportunity to win by providing the best patient care possible.
Graduating team-ready health care professionals requires seasoned educators, those who are experts in best practices not only in the classroom but also in IPE facilitation. As a result of limited experience in IPE facilitation, many educators are slowing the adoption of IPE1 and potentially limiting the capacity of graduates to be ready to practice in a contemporary workplace. Literature to date is limited (but growing) in the area of faculty development for IPE, and existing research is not adequate to consider any method a best practice.2 However, promising findings across existing methodologies indicate the value of modeling IPE knowledge, skills, and attitudes (KSAs); group work; reflection; and appreciation of diversity.1
Educator development is a critical component in the effective delivery of IPE. For an interprofessional team to achieve its purpose, it must capitalize on the diverse knowledge and skills of the team. Delivering educator training in a collaborative framework affords exposure to teammates that promotes learning about each other, from each other, and with each other to devise strategies and solve problems related to classroom delivery or team-based patient care. The literature has established that continuing education that isolates health care professions prevents clinicians from developing collaborative capacities that meet the challenges of today's workplace.3,4 Programs that deliver learning using a teaming approach are best positioned to benefit from the role models and networks that are built into this approach. Faculty and clinicians who are expected to engage in IPE and the team-based learning of future clinicians must be supported with the knowledge and skills necessary to design and facilitate IPE.5
Communication strategies for interprofessional teams
By Dee M. Lance and Kim C. McCullough
General Communication Strategies
The goal of interprofessional teams is to offer patients effective and efficient treatment, and communication is a factor that influences the ability to meet that goal. Klinzing and Klinzing11 have identified some internal and external forces that interfere with the ability to engage in conversations or meetings:
- The mind processes words faster than they can be spoken, which can result in the formulation of responses before the message has been delivered.
- As people try to multitask, they experience divided attention, which can interfere with the ability to sustain attention during meetings.
- Environmental distractors, such as cell phones, noise in the hall, and shuffling feet, can interrupt attention.
If we allow things to compete for our attention when we are in a meeting, then we stop being communication collaborators.
Communication is a complex process, and both speakers and listeners carry responsibility for success. We have identified 9 actions (modified from Seery)20 that can support interprofessional teams in their communication efforts.
1. Use Engaged Listening
We have all experienced talking to people and knowing they were not listening. The listeners may be physically distracted, checking their watch or looking at their phone. They may appear distracted, and it is evident they are thinking about something other than what you are saying.
Engaged listening is required for effective communication, and it involves actually hearing and trying to understand what the speaker intends for you to understand. When listening, you can gain clarification by asking questions or rephrasing what you are hearing so that you're sure you fully understand the message as intended. Lake and her colleagues6 remind us that listeners share responsibility for ensuring they have an accurate and complete understanding of the message. They suggest the following techniques for active listening:
- Resolve differences between verbal and nonverbal messages.
- Reflect your feelings about what is being said.
- Ask clarification questions.
- Restate the speaker's message.
Using these techniques helps make communication a process that is a partnership between speaker and listener.
2. Use Nonverbal Communication
As stated previously, the words we select for the sentences we say make up only 7% of the message being conveyed. For both speaker and listener, the conscious use of proxemics, kinesthetics, facial expression and eye behavior, and paralinguistics can reduce miscommunications. For example, your body language should help convey your words and should indicate your openness to the message being sent. Other nonverbal communication acts, such as standing or sitting (proxemics), hand gestures (kinesthetics), eye contact (facial expression and eye behavior), and voice tone (paralinguistics), can enhance communication. For example, a team member may be more likely to speak openly if you are relaxed, have a friendly tone, and use an open posture with uncrossed legs and arms. Eye contact is also important; too much can be intimidating and too little can indicate you are nervous or disengaged. Conscious use of nonverbal cues can help counteract some of the professional, cultural, and linguistic differences you are likely to encounter on interprofessional teams. You can also use your understanding of nonverbal cues to interpret how other team members are feeling.
3. Be Concise and Clear
Team members' time is important, so you should be as concise as possible. Understanding the purpose of your interaction can help you stay focused and convey only the relevant information, which in turn helps the team achieve its common goal efficiently. You should not sacrifice clarity for conciseness, however. Be mindful of shared meaning; group diversity (e.g., professional, cultural, dialectical) could make jargon, professional acronyms, and colloquialisms problematic. Failure to be both concise and clear can cause frustration and confusion.
4. Be Personable
Everyone likes to work with someone who is pleasant, agreeable, and kind. These are some of the characteristics that could be considered personable. Using both verbal and nonverbal communication can help convey information about yourself. This can be as simple as smiling and nodding when you agree with what is being said, managing your tone so that passion does not sound like aggression, allowing others to state their opinion first so that you appear receptive to other ideas, or adding a personal message to an email so that your communication is less abrupt.
5. Speak With Confidence
When you convey to other team members that you are up to the task, then effective communication can occur. If you sound tentative about your contribution to the team, the team will be cautious about your ability to help meet the goal. Using nonverbal cues such as tone and stance can help portray confidence. You should also listen to the message others are communicating and then use engaged listening to seek clarification.
6. Show Empathy
Empathy, the ability to take the perspective of another person or to understand what someone is feeling, is a foundational skill for successful interactions. You do not have to agree with what people are saying to show that you appreciate their perspective. By saying to your team members, “I understand where you are coming from,” you let them know that you have heard their message. Remember that people from low-context and high-context cultures will react differently to disagreements, so use other tools to ensure relationships among group members stay intact.
7. Stay Open-Minded
We have discussed cultural, dialectical, and gender differences, all of which can influence shared meaning, relationships, and decision making. Using all of your tools to project openness to others' opinions and ideas is necessary for honest and effective communication.
8. Give and Receive Feedback
When you ask for clarification or restate something that has been said, you are providing feedback about your understanding and potentially about the effectiveness of the interaction. This is an essential skill for communication and for the interprofessional team to be efficient and effective. There are other types of devices as well, such as praising someone's presentation or providing supportive, constructive feedback that can strengthen any team. How you give and receive feedback can affect team morale, so having a handle on the cultural differences within the group can help you frame your questions and feedback.
9. Consider the Medium
A large part of figuring out the medium (e.g., oral, written, electronic) for any communication is considering the audience and purpose. Remember, when contemplating a written format, only a small portion of any attempt to communicate is conveyed by the words selected. Sensitive information may best be handled in person. Some communication devices, such as humor and sarcasm, use paralinguistic features and can fall flat when using written language. Additionally, when selecting a communication medium, careful thought should be given to any content that is sensitive or confidential.
Lake and colleagues6 suggest that structured reflection is useful to monitor and increase self-awareness as you practice communication techniques within your interprofessional team. Self-reflection can take the form of journaling and checklists before or after meetings and interactions. Choosing good communication strategies, consciously using them in conversations and meetings, and evaluating both your successes and failures is important for your individual success as well as for doing your part to ensure that the interprofessional team is effective and efficient.
EBP of Teamship: Closed-Loop Communication
Closed-loop communication (CLC) is a well-known team communication technique that has been studied as a mechanism for providing feedback in health care settings when performing collaborative tasks. It is often used during medical procedures and is adaptable for other health care teams. CLC consists of 3 steps:
- A team member calls out an observation or message.
- The second team member confirms that the message was received.
- The first team member confirms that original message was understood correctly.
For example, during a team meeting, a nurse states that the patient is NPO. The PT on the team confirms that the patient cannot be given any food or liquids by mouth. The nurse confirms by stating, “That is correct, the patient cannot be given any food or drink even if the patient requests it.”
In a case study, Johnson and colleagues21 investigated CLC along with two other communication techniques, shared mental model (SMM) and mutual trust (MT). SMM is based on the notion that, over time, team members develop a common context that facilitates understanding and the prediction of outcomes. MT is based on the shared belief that team members will do what they are supposed to do and that their actions will protect the team. The authors found that CLC was most helpful to team communication when used in conjunction with SMM.
Collaborative Corner: Self-Reflection
You may want to start your self-reflection with the following types of questions:
- What message am I sending?
- Who am I trying to convince and why?
- Is the purpose of my communication to achieve a group goal or a personal one?
- Am I open to the other ideas presented?
- How do I want my message received, or how was my message received?
Barriers to professional and collaborative success
By Cindy Mathena
Just as enablers or opportunities have been outlined in the literature as being necessary for success, some barriers exist as well. Many are obvious and include professional cultures promoting silos or stereotypes, use of different language and terminology, accreditors, and a required prescribed curriculum.5,7 Students are educated as they always have been, in schools of nursing, colleges of social work, and departments of athletic training. One can walk into any hospital or medical facility and find that tribalism is still alive and well.13 Nurses are still holding nursing meetings, OTs still have their own department, and PTs are still working at their desks next to each other. This solo work commonly leads one to think of working in a silo. Socialization, communication, IPE, and IPCP are some of the more obvious solutions to this barrier.9,14
Collaboration by the health care team can come at a cost and is difficult to achieve in a hierarchical team where some are seen as the leaders (physicians) and others as the team. A large number of studies validate the presence of professional stereotypes and cultures in the health care workplace.9,13,14 Many argue the solution to silos rests on the shoulders of the educational institution. Learning environments must be created that encourage real-life scenarios where students can learn the complexities of communication and problem solving with other professionals and as a team.
Accreditation requirements can be another barrier, though it should be pointed out that accreditors are also in a position to enable IPE. In the same way we see health care professionals working in a silo, accrediting agencies that certify educational institutions and programs have also historically worked alone. Standards for accreditation are often so prescriptive that little room is left in the curriculum to explore the roles and language of other professionals. Several studies cite limitations in curricula focused on discipline-specific skills and knowledge as a barrier to IPE. Because curricula are often well defined by professional accreditors, integrating other professions and competencies can be challenging.10,15 If universities and institutions play a primary role in the integration of IPCP into the preparation of students in health care, accreditors may have the biggest opportunity to create impactful IPE. It has been suggested that this would include an intersection of accreditors with overlapping standards.
Accreditors occupy a unique position, working within and across professions and health care delivery settings to promote interprofessional collaboration in education and care. Those who work within individual health professions and those accreditors working in different health care delivery domains should look to cross professional and delivery divides for more integrated approaches to the evaluation and regulation of education and clinical practice.15(p2)
Inconsistent and varying terminologies have been recognized as a barrier to IPCP and IPE. In the authors' experience, we have encountered students across health care professions who claim this to be the most significant barrier to IPCP in the health care setting. And while the terminologies used by each discipline may widely vary, our students state that it is important to begin discussions about these differences in the classroom.
Separate to this conversation about terminology is the need to understand that the interpretation of IPCP and IPE may vary by discipline. One study found that nurses and physicians in the operating room defined collaboration very differently. Nurses interpreted it to mean influencing team decisions, whereas physicians interpreted it as meaning their directions would be followed by the other disciplines on the team.16
Additional barriers to IPE implementation were noted in a study of nursing and medical students' perceptions of enablers and barriers. Those barriers included varying knowledge levels, low mutual respect between professions, and capacity and legal issues.7
Create an effective health care team
By K. Michelle Knewstep-Watkins, C. Michelle Longley, and Meghan M. Scanlon
Interprofessional Team Composition
Creating a highly effective health care team is rarely as simple as assembling a group of providers who are knowledgeable and experienced in their clinical practice. Commonly, the group members who will become a health care team are diverse with regard to knowledge, experience, values, and expectations. These differences can present challenges in aligning the team toward a common purpose and accepted processes for meeting the goals.
In some cases, there is an established group of experienced health care providers who have been working together to meet patient needs. These providers may have worked this way for decades, shared many experiences, developed their professional identities in relation to one another, and developed long-standing meaningful friendships. It is critical to recognize that the group may be diverse in the number of years of experience and years working together, which can mean there are established roles, routines, and habits well beyond the simple norms of a scope of practice. However, this does not necessarily mean that these health care providers are a high-functioning team. Similarly, other groups may have a majority of entry-level providers or providers who are new to the group or to serving a particular population, but these characteristics do not necessarily imply that they are a poorly functioning team.
A health care team is effective when all team members understand their role as part of the team as well as the roles and areas of expertise of other team members. One's role on a health care team should not be dictated wholly by profession. For example, patient safety is not solely the responsibility or role of nurses; instead, it is recognized as a shared role. However, it is important to recognize the recommendation of a dietitian in the creation of a patient's nutritional intake, because the dietitian is the professional with the greatest content knowledge in this area, even if other providers have an understanding of nutrition. See chapter 4 for a review of the evidence highlighting the impact of years of experience on IPE and IPCP.
Collaborative workplace environments are routinely associated with improved patient outcomes due to effective workflows and synergistic relationships. Even with shared goals and collaborative relationships, such environments require intentionality. Conflict is an inevitable part of working in teams and stems from individual, contextual, and intrapersonal characteristics that can significantly impair team cohesion and objectives.10 It is important for team participants and leaders to be familiar with sources of group conflict and implement strategies to resolve conflict effectively.
It is also valuable to recognize that teaming in a health care organization occurs on many levels. A team is defined as a group of people who assemble to achieve a common goal, which can occur in any organization regardless of size or complexity. Thus, health care organizations are composed of many layers of teams. The organization as a whole is a team, and additional levels of health care teams are nested within the organization to address cascading goals of the central goal. A medical center may also have diagnosis-centered service areas, such as orthopedics, which are teams within the organization. Additionally, formal teams can assemble to meet a specific need, such as a patient education committee, or informal teams may emerge organically in order to collaborate and address a concern.
Collaborative Corner: Sources of Conflict
Conflict can arise from individual characteristics, contextual factors, or intrapersonal conditions.11
- Individual characteristics—Individual team members enter group settings from different backgrounds with individualized values, opinions, and experiences that lead to assumptions about patient care needs and how to meet them.
- Contextual factors—Situations in which roles and responsibilities are unclear or group goals lack clarity can cause stress and conflict, particularly when combined with fast-paced environments, unpredictability, or high-stakes outcomes.
- Intrapersonal conditions—Conflict is common in circumstances of actual or perceived hierarchical relationships, inconsistent team membership and participation, or limited member or group accountability.
What methods or activities might assist in identifying and addressing individual characteristics, contextual factors, and intrapersonal conditions that contribute to conflict?
Foundation of IPE teaching and learning
By Joy Doll, Anthony Breitbach, and Kathrin Eliot
Scanning the literature on IPE and IPCP quickly reveals that diversity and context dictate the methods of delivery, whether in the academic or clinical environment. IPE and IPCP are not delivered in a one-size-fits-all approach; rather, they challenge educators to consider the learning environment, learning outcomes, and delivery context. For example, in the case study at the beginning of the chapter, IPE was accomplished by faculty champions passionate about the approach, but a clear plan was not in place when institutional support for IPE expanded. However, examples of best practice exist at many academic and clinical institutions. Chapter 1 lends credibility to IPCP regarding benefits to systems, procedures, and health outcomes; however, there remains a gap in the research on how IPE should be implemented.10 Although the lack of a clear road map results in a challenging ambiguity, that same ambiguity offers extensive opportunity to innovate and engage in creative approaches to advance both IPE and IPCP.
As discussed by Masten and colleagues, the road map to IPE is more about implementing culture change than simply taking an educational approach.11 It requires leaders and educators to consider cultural context as a driver for the design and implementation of IPE, which has been presented as a best practice and a deliberate design approach.4Masten and colleagues describe these cultural changes following 5 stages (figure 2.2):
- Stage 1: Awakening—The process of recognizing the value and importance of IPE begins.
- Stage 2: Giving lip service—Leaders and educators move beyond talking about IPE to implementing structures to support it, like faculty time and reward.
- Stage 3: Parallel play—Pockets of IPE exist but are often not institutionalized.
- Stage 4: Group play—IPE curriculum advances, with administrators recognizing the challenges and faculty champions receiving support to move IPE forward.
- Stage 5: Cultural transformation—IPE is being implemented well and is recognized by the wider university.11
Figure 2.2 Stages of IPE development.
This approach provides a road map for the stages of cultural transformation necessary to make IPE a sustained reality (for more on sustainability, see chapter 8). Despite the lack of clear evidence for an ideal IPE curriculum, the literature on teamwork and team science provides extensive support to pedagogical approaches. The reality remains that attitudes, behaviors, and skills that elicit successful IPCP do not require a clear end point of accomplishment or competence; rather, they require educators to prepare students for an ambiguous and unclear journey.13 This chapter provides a foundation to prepare learners (e.g., students, residents, fellows, clinicians, faculty) to gain the attitudes, behaviors, and skills to negotiate the contemporary health care landscape that is keenly focused on population health and societal needs.
Health care is a team sport
By Jordan Hamson-Utley
Health care is a team sport. Just as sport requires athleticism and sport-specific skills operating in synergy toward a goal, health care teams require captains, diverse skill sets, and coordination to improve a patient's health. In basketball, could a team of only point guards beat a championship team? This might be the health care equivalent of a team of only PTs providing care for a patient after a stroke, for example. Additionally, IPCP is essential for health care teams to achieve patient care goals. Each position on a team requires a unique set of skills; without a point guard, a basketball team would lack leadership, ball vision, communication, and a 3-point scoring threat. Similarly, without a case lead, a care team would lack leadership, planning, communication, and an opportunity to win by providing the best patient care possible.
Graduating team-ready health care professionals requires seasoned educators, those who are experts in best practices not only in the classroom but also in IPE facilitation. As a result of limited experience in IPE facilitation, many educators are slowing the adoption of IPE1 and potentially limiting the capacity of graduates to be ready to practice in a contemporary workplace. Literature to date is limited (but growing) in the area of faculty development for IPE, and existing research is not adequate to consider any method a best practice.2 However, promising findings across existing methodologies indicate the value of modeling IPE knowledge, skills, and attitudes (KSAs); group work; reflection; and appreciation of diversity.1
Educator development is a critical component in the effective delivery of IPE. For an interprofessional team to achieve its purpose, it must capitalize on the diverse knowledge and skills of the team. Delivering educator training in a collaborative framework affords exposure to teammates that promotes learning about each other, from each other, and with each other to devise strategies and solve problems related to classroom delivery or team-based patient care. The literature has established that continuing education that isolates health care professions prevents clinicians from developing collaborative capacities that meet the challenges of today's workplace.3,4 Programs that deliver learning using a teaming approach are best positioned to benefit from the role models and networks that are built into this approach. Faculty and clinicians who are expected to engage in IPE and the team-based learning of future clinicians must be supported with the knowledge and skills necessary to design and facilitate IPE.5
Communication strategies for interprofessional teams
By Dee M. Lance and Kim C. McCullough
General Communication Strategies
The goal of interprofessional teams is to offer patients effective and efficient treatment, and communication is a factor that influences the ability to meet that goal. Klinzing and Klinzing11 have identified some internal and external forces that interfere with the ability to engage in conversations or meetings:
- The mind processes words faster than they can be spoken, which can result in the formulation of responses before the message has been delivered.
- As people try to multitask, they experience divided attention, which can interfere with the ability to sustain attention during meetings.
- Environmental distractors, such as cell phones, noise in the hall, and shuffling feet, can interrupt attention.
If we allow things to compete for our attention when we are in a meeting, then we stop being communication collaborators.
Communication is a complex process, and both speakers and listeners carry responsibility for success. We have identified 9 actions (modified from Seery)20 that can support interprofessional teams in their communication efforts.
1. Use Engaged Listening
We have all experienced talking to people and knowing they were not listening. The listeners may be physically distracted, checking their watch or looking at their phone. They may appear distracted, and it is evident they are thinking about something other than what you are saying.
Engaged listening is required for effective communication, and it involves actually hearing and trying to understand what the speaker intends for you to understand. When listening, you can gain clarification by asking questions or rephrasing what you are hearing so that you're sure you fully understand the message as intended. Lake and her colleagues6 remind us that listeners share responsibility for ensuring they have an accurate and complete understanding of the message. They suggest the following techniques for active listening:
- Resolve differences between verbal and nonverbal messages.
- Reflect your feelings about what is being said.
- Ask clarification questions.
- Restate the speaker's message.
Using these techniques helps make communication a process that is a partnership between speaker and listener.
2. Use Nonverbal Communication
As stated previously, the words we select for the sentences we say make up only 7% of the message being conveyed. For both speaker and listener, the conscious use of proxemics, kinesthetics, facial expression and eye behavior, and paralinguistics can reduce miscommunications. For example, your body language should help convey your words and should indicate your openness to the message being sent. Other nonverbal communication acts, such as standing or sitting (proxemics), hand gestures (kinesthetics), eye contact (facial expression and eye behavior), and voice tone (paralinguistics), can enhance communication. For example, a team member may be more likely to speak openly if you are relaxed, have a friendly tone, and use an open posture with uncrossed legs and arms. Eye contact is also important; too much can be intimidating and too little can indicate you are nervous or disengaged. Conscious use of nonverbal cues can help counteract some of the professional, cultural, and linguistic differences you are likely to encounter on interprofessional teams. You can also use your understanding of nonverbal cues to interpret how other team members are feeling.
3. Be Concise and Clear
Team members' time is important, so you should be as concise as possible. Understanding the purpose of your interaction can help you stay focused and convey only the relevant information, which in turn helps the team achieve its common goal efficiently. You should not sacrifice clarity for conciseness, however. Be mindful of shared meaning; group diversity (e.g., professional, cultural, dialectical) could make jargon, professional acronyms, and colloquialisms problematic. Failure to be both concise and clear can cause frustration and confusion.
4. Be Personable
Everyone likes to work with someone who is pleasant, agreeable, and kind. These are some of the characteristics that could be considered personable. Using both verbal and nonverbal communication can help convey information about yourself. This can be as simple as smiling and nodding when you agree with what is being said, managing your tone so that passion does not sound like aggression, allowing others to state their opinion first so that you appear receptive to other ideas, or adding a personal message to an email so that your communication is less abrupt.
5. Speak With Confidence
When you convey to other team members that you are up to the task, then effective communication can occur. If you sound tentative about your contribution to the team, the team will be cautious about your ability to help meet the goal. Using nonverbal cues such as tone and stance can help portray confidence. You should also listen to the message others are communicating and then use engaged listening to seek clarification.
6. Show Empathy
Empathy, the ability to take the perspective of another person or to understand what someone is feeling, is a foundational skill for successful interactions. You do not have to agree with what people are saying to show that you appreciate their perspective. By saying to your team members, “I understand where you are coming from,” you let them know that you have heard their message. Remember that people from low-context and high-context cultures will react differently to disagreements, so use other tools to ensure relationships among group members stay intact.
7. Stay Open-Minded
We have discussed cultural, dialectical, and gender differences, all of which can influence shared meaning, relationships, and decision making. Using all of your tools to project openness to others' opinions and ideas is necessary for honest and effective communication.
8. Give and Receive Feedback
When you ask for clarification or restate something that has been said, you are providing feedback about your understanding and potentially about the effectiveness of the interaction. This is an essential skill for communication and for the interprofessional team to be efficient and effective. There are other types of devices as well, such as praising someone's presentation or providing supportive, constructive feedback that can strengthen any team. How you give and receive feedback can affect team morale, so having a handle on the cultural differences within the group can help you frame your questions and feedback.
9. Consider the Medium
A large part of figuring out the medium (e.g., oral, written, electronic) for any communication is considering the audience and purpose. Remember, when contemplating a written format, only a small portion of any attempt to communicate is conveyed by the words selected. Sensitive information may best be handled in person. Some communication devices, such as humor and sarcasm, use paralinguistic features and can fall flat when using written language. Additionally, when selecting a communication medium, careful thought should be given to any content that is sensitive or confidential.
Lake and colleagues6 suggest that structured reflection is useful to monitor and increase self-awareness as you practice communication techniques within your interprofessional team. Self-reflection can take the form of journaling and checklists before or after meetings and interactions. Choosing good communication strategies, consciously using them in conversations and meetings, and evaluating both your successes and failures is important for your individual success as well as for doing your part to ensure that the interprofessional team is effective and efficient.
EBP of Teamship: Closed-Loop Communication
Closed-loop communication (CLC) is a well-known team communication technique that has been studied as a mechanism for providing feedback in health care settings when performing collaborative tasks. It is often used during medical procedures and is adaptable for other health care teams. CLC consists of 3 steps:
- A team member calls out an observation or message.
- The second team member confirms that the message was received.
- The first team member confirms that original message was understood correctly.
For example, during a team meeting, a nurse states that the patient is NPO. The PT on the team confirms that the patient cannot be given any food or liquids by mouth. The nurse confirms by stating, “That is correct, the patient cannot be given any food or drink even if the patient requests it.”
In a case study, Johnson and colleagues21 investigated CLC along with two other communication techniques, shared mental model (SMM) and mutual trust (MT). SMM is based on the notion that, over time, team members develop a common context that facilitates understanding and the prediction of outcomes. MT is based on the shared belief that team members will do what they are supposed to do and that their actions will protect the team. The authors found that CLC was most helpful to team communication when used in conjunction with SMM.
Collaborative Corner: Self-Reflection
You may want to start your self-reflection with the following types of questions:
- What message am I sending?
- Who am I trying to convince and why?
- Is the purpose of my communication to achieve a group goal or a personal one?
- Am I open to the other ideas presented?
- How do I want my message received, or how was my message received?
Barriers to professional and collaborative success
By Cindy Mathena
Just as enablers or opportunities have been outlined in the literature as being necessary for success, some barriers exist as well. Many are obvious and include professional cultures promoting silos or stereotypes, use of different language and terminology, accreditors, and a required prescribed curriculum.5,7 Students are educated as they always have been, in schools of nursing, colleges of social work, and departments of athletic training. One can walk into any hospital or medical facility and find that tribalism is still alive and well.13 Nurses are still holding nursing meetings, OTs still have their own department, and PTs are still working at their desks next to each other. This solo work commonly leads one to think of working in a silo. Socialization, communication, IPE, and IPCP are some of the more obvious solutions to this barrier.9,14
Collaboration by the health care team can come at a cost and is difficult to achieve in a hierarchical team where some are seen as the leaders (physicians) and others as the team. A large number of studies validate the presence of professional stereotypes and cultures in the health care workplace.9,13,14 Many argue the solution to silos rests on the shoulders of the educational institution. Learning environments must be created that encourage real-life scenarios where students can learn the complexities of communication and problem solving with other professionals and as a team.
Accreditation requirements can be another barrier, though it should be pointed out that accreditors are also in a position to enable IPE. In the same way we see health care professionals working in a silo, accrediting agencies that certify educational institutions and programs have also historically worked alone. Standards for accreditation are often so prescriptive that little room is left in the curriculum to explore the roles and language of other professionals. Several studies cite limitations in curricula focused on discipline-specific skills and knowledge as a barrier to IPE. Because curricula are often well defined by professional accreditors, integrating other professions and competencies can be challenging.10,15 If universities and institutions play a primary role in the integration of IPCP into the preparation of students in health care, accreditors may have the biggest opportunity to create impactful IPE. It has been suggested that this would include an intersection of accreditors with overlapping standards.
Accreditors occupy a unique position, working within and across professions and health care delivery settings to promote interprofessional collaboration in education and care. Those who work within individual health professions and those accreditors working in different health care delivery domains should look to cross professional and delivery divides for more integrated approaches to the evaluation and regulation of education and clinical practice.15(p2)
Inconsistent and varying terminologies have been recognized as a barrier to IPCP and IPE. In the authors' experience, we have encountered students across health care professions who claim this to be the most significant barrier to IPCP in the health care setting. And while the terminologies used by each discipline may widely vary, our students state that it is important to begin discussions about these differences in the classroom.
Separate to this conversation about terminology is the need to understand that the interpretation of IPCP and IPE may vary by discipline. One study found that nurses and physicians in the operating room defined collaboration very differently. Nurses interpreted it to mean influencing team decisions, whereas physicians interpreted it as meaning their directions would be followed by the other disciplines on the team.16
Additional barriers to IPE implementation were noted in a study of nursing and medical students' perceptions of enablers and barriers. Those barriers included varying knowledge levels, low mutual respect between professions, and capacity and legal issues.7
Create an effective health care team
By K. Michelle Knewstep-Watkins, C. Michelle Longley, and Meghan M. Scanlon
Interprofessional Team Composition
Creating a highly effective health care team is rarely as simple as assembling a group of providers who are knowledgeable and experienced in their clinical practice. Commonly, the group members who will become a health care team are diverse with regard to knowledge, experience, values, and expectations. These differences can present challenges in aligning the team toward a common purpose and accepted processes for meeting the goals.
In some cases, there is an established group of experienced health care providers who have been working together to meet patient needs. These providers may have worked this way for decades, shared many experiences, developed their professional identities in relation to one another, and developed long-standing meaningful friendships. It is critical to recognize that the group may be diverse in the number of years of experience and years working together, which can mean there are established roles, routines, and habits well beyond the simple norms of a scope of practice. However, this does not necessarily mean that these health care providers are a high-functioning team. Similarly, other groups may have a majority of entry-level providers or providers who are new to the group or to serving a particular population, but these characteristics do not necessarily imply that they are a poorly functioning team.
A health care team is effective when all team members understand their role as part of the team as well as the roles and areas of expertise of other team members. One's role on a health care team should not be dictated wholly by profession. For example, patient safety is not solely the responsibility or role of nurses; instead, it is recognized as a shared role. However, it is important to recognize the recommendation of a dietitian in the creation of a patient's nutritional intake, because the dietitian is the professional with the greatest content knowledge in this area, even if other providers have an understanding of nutrition. See chapter 4 for a review of the evidence highlighting the impact of years of experience on IPE and IPCP.
Collaborative workplace environments are routinely associated with improved patient outcomes due to effective workflows and synergistic relationships. Even with shared goals and collaborative relationships, such environments require intentionality. Conflict is an inevitable part of working in teams and stems from individual, contextual, and intrapersonal characteristics that can significantly impair team cohesion and objectives.10 It is important for team participants and leaders to be familiar with sources of group conflict and implement strategies to resolve conflict effectively.
It is also valuable to recognize that teaming in a health care organization occurs on many levels. A team is defined as a group of people who assemble to achieve a common goal, which can occur in any organization regardless of size or complexity. Thus, health care organizations are composed of many layers of teams. The organization as a whole is a team, and additional levels of health care teams are nested within the organization to address cascading goals of the central goal. A medical center may also have diagnosis-centered service areas, such as orthopedics, which are teams within the organization. Additionally, formal teams can assemble to meet a specific need, such as a patient education committee, or informal teams may emerge organically in order to collaborate and address a concern.
Collaborative Corner: Sources of Conflict
Conflict can arise from individual characteristics, contextual factors, or intrapersonal conditions.11
- Individual characteristics—Individual team members enter group settings from different backgrounds with individualized values, opinions, and experiences that lead to assumptions about patient care needs and how to meet them.
- Contextual factors—Situations in which roles and responsibilities are unclear or group goals lack clarity can cause stress and conflict, particularly when combined with fast-paced environments, unpredictability, or high-stakes outcomes.
- Intrapersonal conditions—Conflict is common in circumstances of actual or perceived hierarchical relationships, inconsistent team membership and participation, or limited member or group accountability.
What methods or activities might assist in identifying and addressing individual characteristics, contextual factors, and intrapersonal conditions that contribute to conflict?
Foundation of IPE teaching and learning
By Joy Doll, Anthony Breitbach, and Kathrin Eliot
Scanning the literature on IPE and IPCP quickly reveals that diversity and context dictate the methods of delivery, whether in the academic or clinical environment. IPE and IPCP are not delivered in a one-size-fits-all approach; rather, they challenge educators to consider the learning environment, learning outcomes, and delivery context. For example, in the case study at the beginning of the chapter, IPE was accomplished by faculty champions passionate about the approach, but a clear plan was not in place when institutional support for IPE expanded. However, examples of best practice exist at many academic and clinical institutions. Chapter 1 lends credibility to IPCP regarding benefits to systems, procedures, and health outcomes; however, there remains a gap in the research on how IPE should be implemented.10 Although the lack of a clear road map results in a challenging ambiguity, that same ambiguity offers extensive opportunity to innovate and engage in creative approaches to advance both IPE and IPCP.
As discussed by Masten and colleagues, the road map to IPE is more about implementing culture change than simply taking an educational approach.11 It requires leaders and educators to consider cultural context as a driver for the design and implementation of IPE, which has been presented as a best practice and a deliberate design approach.4Masten and colleagues describe these cultural changes following 5 stages (figure 2.2):
- Stage 1: Awakening—The process of recognizing the value and importance of IPE begins.
- Stage 2: Giving lip service—Leaders and educators move beyond talking about IPE to implementing structures to support it, like faculty time and reward.
- Stage 3: Parallel play—Pockets of IPE exist but are often not institutionalized.
- Stage 4: Group play—IPE curriculum advances, with administrators recognizing the challenges and faculty champions receiving support to move IPE forward.
- Stage 5: Cultural transformation—IPE is being implemented well and is recognized by the wider university.11
Figure 2.2 Stages of IPE development.
This approach provides a road map for the stages of cultural transformation necessary to make IPE a sustained reality (for more on sustainability, see chapter 8). Despite the lack of clear evidence for an ideal IPE curriculum, the literature on teamwork and team science provides extensive support to pedagogical approaches. The reality remains that attitudes, behaviors, and skills that elicit successful IPCP do not require a clear end point of accomplishment or competence; rather, they require educators to prepare students for an ambiguous and unclear journey.13 This chapter provides a foundation to prepare learners (e.g., students, residents, fellows, clinicians, faculty) to gain the attitudes, behaviors, and skills to negotiate the contemporary health care landscape that is keenly focused on population health and societal needs.
Health care is a team sport
By Jordan Hamson-Utley
Health care is a team sport. Just as sport requires athleticism and sport-specific skills operating in synergy toward a goal, health care teams require captains, diverse skill sets, and coordination to improve a patient's health. In basketball, could a team of only point guards beat a championship team? This might be the health care equivalent of a team of only PTs providing care for a patient after a stroke, for example. Additionally, IPCP is essential for health care teams to achieve patient care goals. Each position on a team requires a unique set of skills; without a point guard, a basketball team would lack leadership, ball vision, communication, and a 3-point scoring threat. Similarly, without a case lead, a care team would lack leadership, planning, communication, and an opportunity to win by providing the best patient care possible.
Graduating team-ready health care professionals requires seasoned educators, those who are experts in best practices not only in the classroom but also in IPE facilitation. As a result of limited experience in IPE facilitation, many educators are slowing the adoption of IPE1 and potentially limiting the capacity of graduates to be ready to practice in a contemporary workplace. Literature to date is limited (but growing) in the area of faculty development for IPE, and existing research is not adequate to consider any method a best practice.2 However, promising findings across existing methodologies indicate the value of modeling IPE knowledge, skills, and attitudes (KSAs); group work; reflection; and appreciation of diversity.1
Educator development is a critical component in the effective delivery of IPE. For an interprofessional team to achieve its purpose, it must capitalize on the diverse knowledge and skills of the team. Delivering educator training in a collaborative framework affords exposure to teammates that promotes learning about each other, from each other, and with each other to devise strategies and solve problems related to classroom delivery or team-based patient care. The literature has established that continuing education that isolates health care professions prevents clinicians from developing collaborative capacities that meet the challenges of today's workplace.3,4 Programs that deliver learning using a teaming approach are best positioned to benefit from the role models and networks that are built into this approach. Faculty and clinicians who are expected to engage in IPE and the team-based learning of future clinicians must be supported with the knowledge and skills necessary to design and facilitate IPE.5
Communication strategies for interprofessional teams
By Dee M. Lance and Kim C. McCullough
General Communication Strategies
The goal of interprofessional teams is to offer patients effective and efficient treatment, and communication is a factor that influences the ability to meet that goal. Klinzing and Klinzing11 have identified some internal and external forces that interfere with the ability to engage in conversations or meetings:
- The mind processes words faster than they can be spoken, which can result in the formulation of responses before the message has been delivered.
- As people try to multitask, they experience divided attention, which can interfere with the ability to sustain attention during meetings.
- Environmental distractors, such as cell phones, noise in the hall, and shuffling feet, can interrupt attention.
If we allow things to compete for our attention when we are in a meeting, then we stop being communication collaborators.
Communication is a complex process, and both speakers and listeners carry responsibility for success. We have identified 9 actions (modified from Seery)20 that can support interprofessional teams in their communication efforts.
1. Use Engaged Listening
We have all experienced talking to people and knowing they were not listening. The listeners may be physically distracted, checking their watch or looking at their phone. They may appear distracted, and it is evident they are thinking about something other than what you are saying.
Engaged listening is required for effective communication, and it involves actually hearing and trying to understand what the speaker intends for you to understand. When listening, you can gain clarification by asking questions or rephrasing what you are hearing so that you're sure you fully understand the message as intended. Lake and her colleagues6 remind us that listeners share responsibility for ensuring they have an accurate and complete understanding of the message. They suggest the following techniques for active listening:
- Resolve differences between verbal and nonverbal messages.
- Reflect your feelings about what is being said.
- Ask clarification questions.
- Restate the speaker's message.
Using these techniques helps make communication a process that is a partnership between speaker and listener.
2. Use Nonverbal Communication
As stated previously, the words we select for the sentences we say make up only 7% of the message being conveyed. For both speaker and listener, the conscious use of proxemics, kinesthetics, facial expression and eye behavior, and paralinguistics can reduce miscommunications. For example, your body language should help convey your words and should indicate your openness to the message being sent. Other nonverbal communication acts, such as standing or sitting (proxemics), hand gestures (kinesthetics), eye contact (facial expression and eye behavior), and voice tone (paralinguistics), can enhance communication. For example, a team member may be more likely to speak openly if you are relaxed, have a friendly tone, and use an open posture with uncrossed legs and arms. Eye contact is also important; too much can be intimidating and too little can indicate you are nervous or disengaged. Conscious use of nonverbal cues can help counteract some of the professional, cultural, and linguistic differences you are likely to encounter on interprofessional teams. You can also use your understanding of nonverbal cues to interpret how other team members are feeling.
3. Be Concise and Clear
Team members' time is important, so you should be as concise as possible. Understanding the purpose of your interaction can help you stay focused and convey only the relevant information, which in turn helps the team achieve its common goal efficiently. You should not sacrifice clarity for conciseness, however. Be mindful of shared meaning; group diversity (e.g., professional, cultural, dialectical) could make jargon, professional acronyms, and colloquialisms problematic. Failure to be both concise and clear can cause frustration and confusion.
4. Be Personable
Everyone likes to work with someone who is pleasant, agreeable, and kind. These are some of the characteristics that could be considered personable. Using both verbal and nonverbal communication can help convey information about yourself. This can be as simple as smiling and nodding when you agree with what is being said, managing your tone so that passion does not sound like aggression, allowing others to state their opinion first so that you appear receptive to other ideas, or adding a personal message to an email so that your communication is less abrupt.
5. Speak With Confidence
When you convey to other team members that you are up to the task, then effective communication can occur. If you sound tentative about your contribution to the team, the team will be cautious about your ability to help meet the goal. Using nonverbal cues such as tone and stance can help portray confidence. You should also listen to the message others are communicating and then use engaged listening to seek clarification.
6. Show Empathy
Empathy, the ability to take the perspective of another person or to understand what someone is feeling, is a foundational skill for successful interactions. You do not have to agree with what people are saying to show that you appreciate their perspective. By saying to your team members, “I understand where you are coming from,” you let them know that you have heard their message. Remember that people from low-context and high-context cultures will react differently to disagreements, so use other tools to ensure relationships among group members stay intact.
7. Stay Open-Minded
We have discussed cultural, dialectical, and gender differences, all of which can influence shared meaning, relationships, and decision making. Using all of your tools to project openness to others' opinions and ideas is necessary for honest and effective communication.
8. Give and Receive Feedback
When you ask for clarification or restate something that has been said, you are providing feedback about your understanding and potentially about the effectiveness of the interaction. This is an essential skill for communication and for the interprofessional team to be efficient and effective. There are other types of devices as well, such as praising someone's presentation or providing supportive, constructive feedback that can strengthen any team. How you give and receive feedback can affect team morale, so having a handle on the cultural differences within the group can help you frame your questions and feedback.
9. Consider the Medium
A large part of figuring out the medium (e.g., oral, written, electronic) for any communication is considering the audience and purpose. Remember, when contemplating a written format, only a small portion of any attempt to communicate is conveyed by the words selected. Sensitive information may best be handled in person. Some communication devices, such as humor and sarcasm, use paralinguistic features and can fall flat when using written language. Additionally, when selecting a communication medium, careful thought should be given to any content that is sensitive or confidential.
Lake and colleagues6 suggest that structured reflection is useful to monitor and increase self-awareness as you practice communication techniques within your interprofessional team. Self-reflection can take the form of journaling and checklists before or after meetings and interactions. Choosing good communication strategies, consciously using them in conversations and meetings, and evaluating both your successes and failures is important for your individual success as well as for doing your part to ensure that the interprofessional team is effective and efficient.
EBP of Teamship: Closed-Loop Communication
Closed-loop communication (CLC) is a well-known team communication technique that has been studied as a mechanism for providing feedback in health care settings when performing collaborative tasks. It is often used during medical procedures and is adaptable for other health care teams. CLC consists of 3 steps:
- A team member calls out an observation or message.
- The second team member confirms that the message was received.
- The first team member confirms that original message was understood correctly.
For example, during a team meeting, a nurse states that the patient is NPO. The PT on the team confirms that the patient cannot be given any food or liquids by mouth. The nurse confirms by stating, “That is correct, the patient cannot be given any food or drink even if the patient requests it.”
In a case study, Johnson and colleagues21 investigated CLC along with two other communication techniques, shared mental model (SMM) and mutual trust (MT). SMM is based on the notion that, over time, team members develop a common context that facilitates understanding and the prediction of outcomes. MT is based on the shared belief that team members will do what they are supposed to do and that their actions will protect the team. The authors found that CLC was most helpful to team communication when used in conjunction with SMM.
Collaborative Corner: Self-Reflection
You may want to start your self-reflection with the following types of questions:
- What message am I sending?
- Who am I trying to convince and why?
- Is the purpose of my communication to achieve a group goal or a personal one?
- Am I open to the other ideas presented?
- How do I want my message received, or how was my message received?
Barriers to professional and collaborative success
By Cindy Mathena
Just as enablers or opportunities have been outlined in the literature as being necessary for success, some barriers exist as well. Many are obvious and include professional cultures promoting silos or stereotypes, use of different language and terminology, accreditors, and a required prescribed curriculum.5,7 Students are educated as they always have been, in schools of nursing, colleges of social work, and departments of athletic training. One can walk into any hospital or medical facility and find that tribalism is still alive and well.13 Nurses are still holding nursing meetings, OTs still have their own department, and PTs are still working at their desks next to each other. This solo work commonly leads one to think of working in a silo. Socialization, communication, IPE, and IPCP are some of the more obvious solutions to this barrier.9,14
Collaboration by the health care team can come at a cost and is difficult to achieve in a hierarchical team where some are seen as the leaders (physicians) and others as the team. A large number of studies validate the presence of professional stereotypes and cultures in the health care workplace.9,13,14 Many argue the solution to silos rests on the shoulders of the educational institution. Learning environments must be created that encourage real-life scenarios where students can learn the complexities of communication and problem solving with other professionals and as a team.
Accreditation requirements can be another barrier, though it should be pointed out that accreditors are also in a position to enable IPE. In the same way we see health care professionals working in a silo, accrediting agencies that certify educational institutions and programs have also historically worked alone. Standards for accreditation are often so prescriptive that little room is left in the curriculum to explore the roles and language of other professionals. Several studies cite limitations in curricula focused on discipline-specific skills and knowledge as a barrier to IPE. Because curricula are often well defined by professional accreditors, integrating other professions and competencies can be challenging.10,15 If universities and institutions play a primary role in the integration of IPCP into the preparation of students in health care, accreditors may have the biggest opportunity to create impactful IPE. It has been suggested that this would include an intersection of accreditors with overlapping standards.
Accreditors occupy a unique position, working within and across professions and health care delivery settings to promote interprofessional collaboration in education and care. Those who work within individual health professions and those accreditors working in different health care delivery domains should look to cross professional and delivery divides for more integrated approaches to the evaluation and regulation of education and clinical practice.15(p2)
Inconsistent and varying terminologies have been recognized as a barrier to IPCP and IPE. In the authors' experience, we have encountered students across health care professions who claim this to be the most significant barrier to IPCP in the health care setting. And while the terminologies used by each discipline may widely vary, our students state that it is important to begin discussions about these differences in the classroom.
Separate to this conversation about terminology is the need to understand that the interpretation of IPCP and IPE may vary by discipline. One study found that nurses and physicians in the operating room defined collaboration very differently. Nurses interpreted it to mean influencing team decisions, whereas physicians interpreted it as meaning their directions would be followed by the other disciplines on the team.16
Additional barriers to IPE implementation were noted in a study of nursing and medical students' perceptions of enablers and barriers. Those barriers included varying knowledge levels, low mutual respect between professions, and capacity and legal issues.7
Create an effective health care team
By K. Michelle Knewstep-Watkins, C. Michelle Longley, and Meghan M. Scanlon
Interprofessional Team Composition
Creating a highly effective health care team is rarely as simple as assembling a group of providers who are knowledgeable and experienced in their clinical practice. Commonly, the group members who will become a health care team are diverse with regard to knowledge, experience, values, and expectations. These differences can present challenges in aligning the team toward a common purpose and accepted processes for meeting the goals.
In some cases, there is an established group of experienced health care providers who have been working together to meet patient needs. These providers may have worked this way for decades, shared many experiences, developed their professional identities in relation to one another, and developed long-standing meaningful friendships. It is critical to recognize that the group may be diverse in the number of years of experience and years working together, which can mean there are established roles, routines, and habits well beyond the simple norms of a scope of practice. However, this does not necessarily mean that these health care providers are a high-functioning team. Similarly, other groups may have a majority of entry-level providers or providers who are new to the group or to serving a particular population, but these characteristics do not necessarily imply that they are a poorly functioning team.
A health care team is effective when all team members understand their role as part of the team as well as the roles and areas of expertise of other team members. One's role on a health care team should not be dictated wholly by profession. For example, patient safety is not solely the responsibility or role of nurses; instead, it is recognized as a shared role. However, it is important to recognize the recommendation of a dietitian in the creation of a patient's nutritional intake, because the dietitian is the professional with the greatest content knowledge in this area, even if other providers have an understanding of nutrition. See chapter 4 for a review of the evidence highlighting the impact of years of experience on IPE and IPCP.
Collaborative workplace environments are routinely associated with improved patient outcomes due to effective workflows and synergistic relationships. Even with shared goals and collaborative relationships, such environments require intentionality. Conflict is an inevitable part of working in teams and stems from individual, contextual, and intrapersonal characteristics that can significantly impair team cohesion and objectives.10 It is important for team participants and leaders to be familiar with sources of group conflict and implement strategies to resolve conflict effectively.
It is also valuable to recognize that teaming in a health care organization occurs on many levels. A team is defined as a group of people who assemble to achieve a common goal, which can occur in any organization regardless of size or complexity. Thus, health care organizations are composed of many layers of teams. The organization as a whole is a team, and additional levels of health care teams are nested within the organization to address cascading goals of the central goal. A medical center may also have diagnosis-centered service areas, such as orthopedics, which are teams within the organization. Additionally, formal teams can assemble to meet a specific need, such as a patient education committee, or informal teams may emerge organically in order to collaborate and address a concern.
Collaborative Corner: Sources of Conflict
Conflict can arise from individual characteristics, contextual factors, or intrapersonal conditions.11
- Individual characteristics—Individual team members enter group settings from different backgrounds with individualized values, opinions, and experiences that lead to assumptions about patient care needs and how to meet them.
- Contextual factors—Situations in which roles and responsibilities are unclear or group goals lack clarity can cause stress and conflict, particularly when combined with fast-paced environments, unpredictability, or high-stakes outcomes.
- Intrapersonal conditions—Conflict is common in circumstances of actual or perceived hierarchical relationships, inconsistent team membership and participation, or limited member or group accountability.
What methods or activities might assist in identifying and addressing individual characteristics, contextual factors, and intrapersonal conditions that contribute to conflict?
Foundation of IPE teaching and learning
By Joy Doll, Anthony Breitbach, and Kathrin Eliot
Scanning the literature on IPE and IPCP quickly reveals that diversity and context dictate the methods of delivery, whether in the academic or clinical environment. IPE and IPCP are not delivered in a one-size-fits-all approach; rather, they challenge educators to consider the learning environment, learning outcomes, and delivery context. For example, in the case study at the beginning of the chapter, IPE was accomplished by faculty champions passionate about the approach, but a clear plan was not in place when institutional support for IPE expanded. However, examples of best practice exist at many academic and clinical institutions. Chapter 1 lends credibility to IPCP regarding benefits to systems, procedures, and health outcomes; however, there remains a gap in the research on how IPE should be implemented.10 Although the lack of a clear road map results in a challenging ambiguity, that same ambiguity offers extensive opportunity to innovate and engage in creative approaches to advance both IPE and IPCP.
As discussed by Masten and colleagues, the road map to IPE is more about implementing culture change than simply taking an educational approach.11 It requires leaders and educators to consider cultural context as a driver for the design and implementation of IPE, which has been presented as a best practice and a deliberate design approach.4Masten and colleagues describe these cultural changes following 5 stages (figure 2.2):
- Stage 1: Awakening—The process of recognizing the value and importance of IPE begins.
- Stage 2: Giving lip service—Leaders and educators move beyond talking about IPE to implementing structures to support it, like faculty time and reward.
- Stage 3: Parallel play—Pockets of IPE exist but are often not institutionalized.
- Stage 4: Group play—IPE curriculum advances, with administrators recognizing the challenges and faculty champions receiving support to move IPE forward.
- Stage 5: Cultural transformation—IPE is being implemented well and is recognized by the wider university.11
Figure 2.2 Stages of IPE development.
This approach provides a road map for the stages of cultural transformation necessary to make IPE a sustained reality (for more on sustainability, see chapter 8). Despite the lack of clear evidence for an ideal IPE curriculum, the literature on teamwork and team science provides extensive support to pedagogical approaches. The reality remains that attitudes, behaviors, and skills that elicit successful IPCP do not require a clear end point of accomplishment or competence; rather, they require educators to prepare students for an ambiguous and unclear journey.13 This chapter provides a foundation to prepare learners (e.g., students, residents, fellows, clinicians, faculty) to gain the attitudes, behaviors, and skills to negotiate the contemporary health care landscape that is keenly focused on population health and societal needs.
Health care is a team sport
By Jordan Hamson-Utley
Health care is a team sport. Just as sport requires athleticism and sport-specific skills operating in synergy toward a goal, health care teams require captains, diverse skill sets, and coordination to improve a patient's health. In basketball, could a team of only point guards beat a championship team? This might be the health care equivalent of a team of only PTs providing care for a patient after a stroke, for example. Additionally, IPCP is essential for health care teams to achieve patient care goals. Each position on a team requires a unique set of skills; without a point guard, a basketball team would lack leadership, ball vision, communication, and a 3-point scoring threat. Similarly, without a case lead, a care team would lack leadership, planning, communication, and an opportunity to win by providing the best patient care possible.
Graduating team-ready health care professionals requires seasoned educators, those who are experts in best practices not only in the classroom but also in IPE facilitation. As a result of limited experience in IPE facilitation, many educators are slowing the adoption of IPE1 and potentially limiting the capacity of graduates to be ready to practice in a contemporary workplace. Literature to date is limited (but growing) in the area of faculty development for IPE, and existing research is not adequate to consider any method a best practice.2 However, promising findings across existing methodologies indicate the value of modeling IPE knowledge, skills, and attitudes (KSAs); group work; reflection; and appreciation of diversity.1
Educator development is a critical component in the effective delivery of IPE. For an interprofessional team to achieve its purpose, it must capitalize on the diverse knowledge and skills of the team. Delivering educator training in a collaborative framework affords exposure to teammates that promotes learning about each other, from each other, and with each other to devise strategies and solve problems related to classroom delivery or team-based patient care. The literature has established that continuing education that isolates health care professions prevents clinicians from developing collaborative capacities that meet the challenges of today's workplace.3,4 Programs that deliver learning using a teaming approach are best positioned to benefit from the role models and networks that are built into this approach. Faculty and clinicians who are expected to engage in IPE and the team-based learning of future clinicians must be supported with the knowledge and skills necessary to design and facilitate IPE.5
Communication strategies for interprofessional teams
By Dee M. Lance and Kim C. McCullough
General Communication Strategies
The goal of interprofessional teams is to offer patients effective and efficient treatment, and communication is a factor that influences the ability to meet that goal. Klinzing and Klinzing11 have identified some internal and external forces that interfere with the ability to engage in conversations or meetings:
- The mind processes words faster than they can be spoken, which can result in the formulation of responses before the message has been delivered.
- As people try to multitask, they experience divided attention, which can interfere with the ability to sustain attention during meetings.
- Environmental distractors, such as cell phones, noise in the hall, and shuffling feet, can interrupt attention.
If we allow things to compete for our attention when we are in a meeting, then we stop being communication collaborators.
Communication is a complex process, and both speakers and listeners carry responsibility for success. We have identified 9 actions (modified from Seery)20 that can support interprofessional teams in their communication efforts.
1. Use Engaged Listening
We have all experienced talking to people and knowing they were not listening. The listeners may be physically distracted, checking their watch or looking at their phone. They may appear distracted, and it is evident they are thinking about something other than what you are saying.
Engaged listening is required for effective communication, and it involves actually hearing and trying to understand what the speaker intends for you to understand. When listening, you can gain clarification by asking questions or rephrasing what you are hearing so that you're sure you fully understand the message as intended. Lake and her colleagues6 remind us that listeners share responsibility for ensuring they have an accurate and complete understanding of the message. They suggest the following techniques for active listening:
- Resolve differences between verbal and nonverbal messages.
- Reflect your feelings about what is being said.
- Ask clarification questions.
- Restate the speaker's message.
Using these techniques helps make communication a process that is a partnership between speaker and listener.
2. Use Nonverbal Communication
As stated previously, the words we select for the sentences we say make up only 7% of the message being conveyed. For both speaker and listener, the conscious use of proxemics, kinesthetics, facial expression and eye behavior, and paralinguistics can reduce miscommunications. For example, your body language should help convey your words and should indicate your openness to the message being sent. Other nonverbal communication acts, such as standing or sitting (proxemics), hand gestures (kinesthetics), eye contact (facial expression and eye behavior), and voice tone (paralinguistics), can enhance communication. For example, a team member may be more likely to speak openly if you are relaxed, have a friendly tone, and use an open posture with uncrossed legs and arms. Eye contact is also important; too much can be intimidating and too little can indicate you are nervous or disengaged. Conscious use of nonverbal cues can help counteract some of the professional, cultural, and linguistic differences you are likely to encounter on interprofessional teams. You can also use your understanding of nonverbal cues to interpret how other team members are feeling.
3. Be Concise and Clear
Team members' time is important, so you should be as concise as possible. Understanding the purpose of your interaction can help you stay focused and convey only the relevant information, which in turn helps the team achieve its common goal efficiently. You should not sacrifice clarity for conciseness, however. Be mindful of shared meaning; group diversity (e.g., professional, cultural, dialectical) could make jargon, professional acronyms, and colloquialisms problematic. Failure to be both concise and clear can cause frustration and confusion.
4. Be Personable
Everyone likes to work with someone who is pleasant, agreeable, and kind. These are some of the characteristics that could be considered personable. Using both verbal and nonverbal communication can help convey information about yourself. This can be as simple as smiling and nodding when you agree with what is being said, managing your tone so that passion does not sound like aggression, allowing others to state their opinion first so that you appear receptive to other ideas, or adding a personal message to an email so that your communication is less abrupt.
5. Speak With Confidence
When you convey to other team members that you are up to the task, then effective communication can occur. If you sound tentative about your contribution to the team, the team will be cautious about your ability to help meet the goal. Using nonverbal cues such as tone and stance can help portray confidence. You should also listen to the message others are communicating and then use engaged listening to seek clarification.
6. Show Empathy
Empathy, the ability to take the perspective of another person or to understand what someone is feeling, is a foundational skill for successful interactions. You do not have to agree with what people are saying to show that you appreciate their perspective. By saying to your team members, “I understand where you are coming from,” you let them know that you have heard their message. Remember that people from low-context and high-context cultures will react differently to disagreements, so use other tools to ensure relationships among group members stay intact.
7. Stay Open-Minded
We have discussed cultural, dialectical, and gender differences, all of which can influence shared meaning, relationships, and decision making. Using all of your tools to project openness to others' opinions and ideas is necessary for honest and effective communication.
8. Give and Receive Feedback
When you ask for clarification or restate something that has been said, you are providing feedback about your understanding and potentially about the effectiveness of the interaction. This is an essential skill for communication and for the interprofessional team to be efficient and effective. There are other types of devices as well, such as praising someone's presentation or providing supportive, constructive feedback that can strengthen any team. How you give and receive feedback can affect team morale, so having a handle on the cultural differences within the group can help you frame your questions and feedback.
9. Consider the Medium
A large part of figuring out the medium (e.g., oral, written, electronic) for any communication is considering the audience and purpose. Remember, when contemplating a written format, only a small portion of any attempt to communicate is conveyed by the words selected. Sensitive information may best be handled in person. Some communication devices, such as humor and sarcasm, use paralinguistic features and can fall flat when using written language. Additionally, when selecting a communication medium, careful thought should be given to any content that is sensitive or confidential.
Lake and colleagues6 suggest that structured reflection is useful to monitor and increase self-awareness as you practice communication techniques within your interprofessional team. Self-reflection can take the form of journaling and checklists before or after meetings and interactions. Choosing good communication strategies, consciously using them in conversations and meetings, and evaluating both your successes and failures is important for your individual success as well as for doing your part to ensure that the interprofessional team is effective and efficient.
EBP of Teamship: Closed-Loop Communication
Closed-loop communication (CLC) is a well-known team communication technique that has been studied as a mechanism for providing feedback in health care settings when performing collaborative tasks. It is often used during medical procedures and is adaptable for other health care teams. CLC consists of 3 steps:
- A team member calls out an observation or message.
- The second team member confirms that the message was received.
- The first team member confirms that original message was understood correctly.
For example, during a team meeting, a nurse states that the patient is NPO. The PT on the team confirms that the patient cannot be given any food or liquids by mouth. The nurse confirms by stating, “That is correct, the patient cannot be given any food or drink even if the patient requests it.”
In a case study, Johnson and colleagues21 investigated CLC along with two other communication techniques, shared mental model (SMM) and mutual trust (MT). SMM is based on the notion that, over time, team members develop a common context that facilitates understanding and the prediction of outcomes. MT is based on the shared belief that team members will do what they are supposed to do and that their actions will protect the team. The authors found that CLC was most helpful to team communication when used in conjunction with SMM.
Collaborative Corner: Self-Reflection
You may want to start your self-reflection with the following types of questions:
- What message am I sending?
- Who am I trying to convince and why?
- Is the purpose of my communication to achieve a group goal or a personal one?
- Am I open to the other ideas presented?
- How do I want my message received, or how was my message received?
Barriers to professional and collaborative success
By Cindy Mathena
Just as enablers or opportunities have been outlined in the literature as being necessary for success, some barriers exist as well. Many are obvious and include professional cultures promoting silos or stereotypes, use of different language and terminology, accreditors, and a required prescribed curriculum.5,7 Students are educated as they always have been, in schools of nursing, colleges of social work, and departments of athletic training. One can walk into any hospital or medical facility and find that tribalism is still alive and well.13 Nurses are still holding nursing meetings, OTs still have their own department, and PTs are still working at their desks next to each other. This solo work commonly leads one to think of working in a silo. Socialization, communication, IPE, and IPCP are some of the more obvious solutions to this barrier.9,14
Collaboration by the health care team can come at a cost and is difficult to achieve in a hierarchical team where some are seen as the leaders (physicians) and others as the team. A large number of studies validate the presence of professional stereotypes and cultures in the health care workplace.9,13,14 Many argue the solution to silos rests on the shoulders of the educational institution. Learning environments must be created that encourage real-life scenarios where students can learn the complexities of communication and problem solving with other professionals and as a team.
Accreditation requirements can be another barrier, though it should be pointed out that accreditors are also in a position to enable IPE. In the same way we see health care professionals working in a silo, accrediting agencies that certify educational institutions and programs have also historically worked alone. Standards for accreditation are often so prescriptive that little room is left in the curriculum to explore the roles and language of other professionals. Several studies cite limitations in curricula focused on discipline-specific skills and knowledge as a barrier to IPE. Because curricula are often well defined by professional accreditors, integrating other professions and competencies can be challenging.10,15 If universities and institutions play a primary role in the integration of IPCP into the preparation of students in health care, accreditors may have the biggest opportunity to create impactful IPE. It has been suggested that this would include an intersection of accreditors with overlapping standards.
Accreditors occupy a unique position, working within and across professions and health care delivery settings to promote interprofessional collaboration in education and care. Those who work within individual health professions and those accreditors working in different health care delivery domains should look to cross professional and delivery divides for more integrated approaches to the evaluation and regulation of education and clinical practice.15(p2)
Inconsistent and varying terminologies have been recognized as a barrier to IPCP and IPE. In the authors' experience, we have encountered students across health care professions who claim this to be the most significant barrier to IPCP in the health care setting. And while the terminologies used by each discipline may widely vary, our students state that it is important to begin discussions about these differences in the classroom.
Separate to this conversation about terminology is the need to understand that the interpretation of IPCP and IPE may vary by discipline. One study found that nurses and physicians in the operating room defined collaboration very differently. Nurses interpreted it to mean influencing team decisions, whereas physicians interpreted it as meaning their directions would be followed by the other disciplines on the team.16
Additional barriers to IPE implementation were noted in a study of nursing and medical students' perceptions of enablers and barriers. Those barriers included varying knowledge levels, low mutual respect between professions, and capacity and legal issues.7
Create an effective health care team
By K. Michelle Knewstep-Watkins, C. Michelle Longley, and Meghan M. Scanlon
Interprofessional Team Composition
Creating a highly effective health care team is rarely as simple as assembling a group of providers who are knowledgeable and experienced in their clinical practice. Commonly, the group members who will become a health care team are diverse with regard to knowledge, experience, values, and expectations. These differences can present challenges in aligning the team toward a common purpose and accepted processes for meeting the goals.
In some cases, there is an established group of experienced health care providers who have been working together to meet patient needs. These providers may have worked this way for decades, shared many experiences, developed their professional identities in relation to one another, and developed long-standing meaningful friendships. It is critical to recognize that the group may be diverse in the number of years of experience and years working together, which can mean there are established roles, routines, and habits well beyond the simple norms of a scope of practice. However, this does not necessarily mean that these health care providers are a high-functioning team. Similarly, other groups may have a majority of entry-level providers or providers who are new to the group or to serving a particular population, but these characteristics do not necessarily imply that they are a poorly functioning team.
A health care team is effective when all team members understand their role as part of the team as well as the roles and areas of expertise of other team members. One's role on a health care team should not be dictated wholly by profession. For example, patient safety is not solely the responsibility or role of nurses; instead, it is recognized as a shared role. However, it is important to recognize the recommendation of a dietitian in the creation of a patient's nutritional intake, because the dietitian is the professional with the greatest content knowledge in this area, even if other providers have an understanding of nutrition. See chapter 4 for a review of the evidence highlighting the impact of years of experience on IPE and IPCP.
Collaborative workplace environments are routinely associated with improved patient outcomes due to effective workflows and synergistic relationships. Even with shared goals and collaborative relationships, such environments require intentionality. Conflict is an inevitable part of working in teams and stems from individual, contextual, and intrapersonal characteristics that can significantly impair team cohesion and objectives.10 It is important for team participants and leaders to be familiar with sources of group conflict and implement strategies to resolve conflict effectively.
It is also valuable to recognize that teaming in a health care organization occurs on many levels. A team is defined as a group of people who assemble to achieve a common goal, which can occur in any organization regardless of size or complexity. Thus, health care organizations are composed of many layers of teams. The organization as a whole is a team, and additional levels of health care teams are nested within the organization to address cascading goals of the central goal. A medical center may also have diagnosis-centered service areas, such as orthopedics, which are teams within the organization. Additionally, formal teams can assemble to meet a specific need, such as a patient education committee, or informal teams may emerge organically in order to collaborate and address a concern.
Collaborative Corner: Sources of Conflict
Conflict can arise from individual characteristics, contextual factors, or intrapersonal conditions.11
- Individual characteristics—Individual team members enter group settings from different backgrounds with individualized values, opinions, and experiences that lead to assumptions about patient care needs and how to meet them.
- Contextual factors—Situations in which roles and responsibilities are unclear or group goals lack clarity can cause stress and conflict, particularly when combined with fast-paced environments, unpredictability, or high-stakes outcomes.
- Intrapersonal conditions—Conflict is common in circumstances of actual or perceived hierarchical relationships, inconsistent team membership and participation, or limited member or group accountability.
What methods or activities might assist in identifying and addressing individual characteristics, contextual factors, and intrapersonal conditions that contribute to conflict?
Foundation of IPE teaching and learning
By Joy Doll, Anthony Breitbach, and Kathrin Eliot
Scanning the literature on IPE and IPCP quickly reveals that diversity and context dictate the methods of delivery, whether in the academic or clinical environment. IPE and IPCP are not delivered in a one-size-fits-all approach; rather, they challenge educators to consider the learning environment, learning outcomes, and delivery context. For example, in the case study at the beginning of the chapter, IPE was accomplished by faculty champions passionate about the approach, but a clear plan was not in place when institutional support for IPE expanded. However, examples of best practice exist at many academic and clinical institutions. Chapter 1 lends credibility to IPCP regarding benefits to systems, procedures, and health outcomes; however, there remains a gap in the research on how IPE should be implemented.10 Although the lack of a clear road map results in a challenging ambiguity, that same ambiguity offers extensive opportunity to innovate and engage in creative approaches to advance both IPE and IPCP.
As discussed by Masten and colleagues, the road map to IPE is more about implementing culture change than simply taking an educational approach.11 It requires leaders and educators to consider cultural context as a driver for the design and implementation of IPE, which has been presented as a best practice and a deliberate design approach.4Masten and colleagues describe these cultural changes following 5 stages (figure 2.2):
- Stage 1: Awakening—The process of recognizing the value and importance of IPE begins.
- Stage 2: Giving lip service—Leaders and educators move beyond talking about IPE to implementing structures to support it, like faculty time and reward.
- Stage 3: Parallel play—Pockets of IPE exist but are often not institutionalized.
- Stage 4: Group play—IPE curriculum advances, with administrators recognizing the challenges and faculty champions receiving support to move IPE forward.
- Stage 5: Cultural transformation—IPE is being implemented well and is recognized by the wider university.11
Figure 2.2 Stages of IPE development.
This approach provides a road map for the stages of cultural transformation necessary to make IPE a sustained reality (for more on sustainability, see chapter 8). Despite the lack of clear evidence for an ideal IPE curriculum, the literature on teamwork and team science provides extensive support to pedagogical approaches. The reality remains that attitudes, behaviors, and skills that elicit successful IPCP do not require a clear end point of accomplishment or competence; rather, they require educators to prepare students for an ambiguous and unclear journey.13 This chapter provides a foundation to prepare learners (e.g., students, residents, fellows, clinicians, faculty) to gain the attitudes, behaviors, and skills to negotiate the contemporary health care landscape that is keenly focused on population health and societal needs.
Health care is a team sport
By Jordan Hamson-Utley
Health care is a team sport. Just as sport requires athleticism and sport-specific skills operating in synergy toward a goal, health care teams require captains, diverse skill sets, and coordination to improve a patient's health. In basketball, could a team of only point guards beat a championship team? This might be the health care equivalent of a team of only PTs providing care for a patient after a stroke, for example. Additionally, IPCP is essential for health care teams to achieve patient care goals. Each position on a team requires a unique set of skills; without a point guard, a basketball team would lack leadership, ball vision, communication, and a 3-point scoring threat. Similarly, without a case lead, a care team would lack leadership, planning, communication, and an opportunity to win by providing the best patient care possible.
Graduating team-ready health care professionals requires seasoned educators, those who are experts in best practices not only in the classroom but also in IPE facilitation. As a result of limited experience in IPE facilitation, many educators are slowing the adoption of IPE1 and potentially limiting the capacity of graduates to be ready to practice in a contemporary workplace. Literature to date is limited (but growing) in the area of faculty development for IPE, and existing research is not adequate to consider any method a best practice.2 However, promising findings across existing methodologies indicate the value of modeling IPE knowledge, skills, and attitudes (KSAs); group work; reflection; and appreciation of diversity.1
Educator development is a critical component in the effective delivery of IPE. For an interprofessional team to achieve its purpose, it must capitalize on the diverse knowledge and skills of the team. Delivering educator training in a collaborative framework affords exposure to teammates that promotes learning about each other, from each other, and with each other to devise strategies and solve problems related to classroom delivery or team-based patient care. The literature has established that continuing education that isolates health care professions prevents clinicians from developing collaborative capacities that meet the challenges of today's workplace.3,4 Programs that deliver learning using a teaming approach are best positioned to benefit from the role models and networks that are built into this approach. Faculty and clinicians who are expected to engage in IPE and the team-based learning of future clinicians must be supported with the knowledge and skills necessary to design and facilitate IPE.5
Communication strategies for interprofessional teams
By Dee M. Lance and Kim C. McCullough
General Communication Strategies
The goal of interprofessional teams is to offer patients effective and efficient treatment, and communication is a factor that influences the ability to meet that goal. Klinzing and Klinzing11 have identified some internal and external forces that interfere with the ability to engage in conversations or meetings:
- The mind processes words faster than they can be spoken, which can result in the formulation of responses before the message has been delivered.
- As people try to multitask, they experience divided attention, which can interfere with the ability to sustain attention during meetings.
- Environmental distractors, such as cell phones, noise in the hall, and shuffling feet, can interrupt attention.
If we allow things to compete for our attention when we are in a meeting, then we stop being communication collaborators.
Communication is a complex process, and both speakers and listeners carry responsibility for success. We have identified 9 actions (modified from Seery)20 that can support interprofessional teams in their communication efforts.
1. Use Engaged Listening
We have all experienced talking to people and knowing they were not listening. The listeners may be physically distracted, checking their watch or looking at their phone. They may appear distracted, and it is evident they are thinking about something other than what you are saying.
Engaged listening is required for effective communication, and it involves actually hearing and trying to understand what the speaker intends for you to understand. When listening, you can gain clarification by asking questions or rephrasing what you are hearing so that you're sure you fully understand the message as intended. Lake and her colleagues6 remind us that listeners share responsibility for ensuring they have an accurate and complete understanding of the message. They suggest the following techniques for active listening:
- Resolve differences between verbal and nonverbal messages.
- Reflect your feelings about what is being said.
- Ask clarification questions.
- Restate the speaker's message.
Using these techniques helps make communication a process that is a partnership between speaker and listener.
2. Use Nonverbal Communication
As stated previously, the words we select for the sentences we say make up only 7% of the message being conveyed. For both speaker and listener, the conscious use of proxemics, kinesthetics, facial expression and eye behavior, and paralinguistics can reduce miscommunications. For example, your body language should help convey your words and should indicate your openness to the message being sent. Other nonverbal communication acts, such as standing or sitting (proxemics), hand gestures (kinesthetics), eye contact (facial expression and eye behavior), and voice tone (paralinguistics), can enhance communication. For example, a team member may be more likely to speak openly if you are relaxed, have a friendly tone, and use an open posture with uncrossed legs and arms. Eye contact is also important; too much can be intimidating and too little can indicate you are nervous or disengaged. Conscious use of nonverbal cues can help counteract some of the professional, cultural, and linguistic differences you are likely to encounter on interprofessional teams. You can also use your understanding of nonverbal cues to interpret how other team members are feeling.
3. Be Concise and Clear
Team members' time is important, so you should be as concise as possible. Understanding the purpose of your interaction can help you stay focused and convey only the relevant information, which in turn helps the team achieve its common goal efficiently. You should not sacrifice clarity for conciseness, however. Be mindful of shared meaning; group diversity (e.g., professional, cultural, dialectical) could make jargon, professional acronyms, and colloquialisms problematic. Failure to be both concise and clear can cause frustration and confusion.
4. Be Personable
Everyone likes to work with someone who is pleasant, agreeable, and kind. These are some of the characteristics that could be considered personable. Using both verbal and nonverbal communication can help convey information about yourself. This can be as simple as smiling and nodding when you agree with what is being said, managing your tone so that passion does not sound like aggression, allowing others to state their opinion first so that you appear receptive to other ideas, or adding a personal message to an email so that your communication is less abrupt.
5. Speak With Confidence
When you convey to other team members that you are up to the task, then effective communication can occur. If you sound tentative about your contribution to the team, the team will be cautious about your ability to help meet the goal. Using nonverbal cues such as tone and stance can help portray confidence. You should also listen to the message others are communicating and then use engaged listening to seek clarification.
6. Show Empathy
Empathy, the ability to take the perspective of another person or to understand what someone is feeling, is a foundational skill for successful interactions. You do not have to agree with what people are saying to show that you appreciate their perspective. By saying to your team members, “I understand where you are coming from,” you let them know that you have heard their message. Remember that people from low-context and high-context cultures will react differently to disagreements, so use other tools to ensure relationships among group members stay intact.
7. Stay Open-Minded
We have discussed cultural, dialectical, and gender differences, all of which can influence shared meaning, relationships, and decision making. Using all of your tools to project openness to others' opinions and ideas is necessary for honest and effective communication.
8. Give and Receive Feedback
When you ask for clarification or restate something that has been said, you are providing feedback about your understanding and potentially about the effectiveness of the interaction. This is an essential skill for communication and for the interprofessional team to be efficient and effective. There are other types of devices as well, such as praising someone's presentation or providing supportive, constructive feedback that can strengthen any team. How you give and receive feedback can affect team morale, so having a handle on the cultural differences within the group can help you frame your questions and feedback.
9. Consider the Medium
A large part of figuring out the medium (e.g., oral, written, electronic) for any communication is considering the audience and purpose. Remember, when contemplating a written format, only a small portion of any attempt to communicate is conveyed by the words selected. Sensitive information may best be handled in person. Some communication devices, such as humor and sarcasm, use paralinguistic features and can fall flat when using written language. Additionally, when selecting a communication medium, careful thought should be given to any content that is sensitive or confidential.
Lake and colleagues6 suggest that structured reflection is useful to monitor and increase self-awareness as you practice communication techniques within your interprofessional team. Self-reflection can take the form of journaling and checklists before or after meetings and interactions. Choosing good communication strategies, consciously using them in conversations and meetings, and evaluating both your successes and failures is important for your individual success as well as for doing your part to ensure that the interprofessional team is effective and efficient.
EBP of Teamship: Closed-Loop Communication
Closed-loop communication (CLC) is a well-known team communication technique that has been studied as a mechanism for providing feedback in health care settings when performing collaborative tasks. It is often used during medical procedures and is adaptable for other health care teams. CLC consists of 3 steps:
- A team member calls out an observation or message.
- The second team member confirms that the message was received.
- The first team member confirms that original message was understood correctly.
For example, during a team meeting, a nurse states that the patient is NPO. The PT on the team confirms that the patient cannot be given any food or liquids by mouth. The nurse confirms by stating, “That is correct, the patient cannot be given any food or drink even if the patient requests it.”
In a case study, Johnson and colleagues21 investigated CLC along with two other communication techniques, shared mental model (SMM) and mutual trust (MT). SMM is based on the notion that, over time, team members develop a common context that facilitates understanding and the prediction of outcomes. MT is based on the shared belief that team members will do what they are supposed to do and that their actions will protect the team. The authors found that CLC was most helpful to team communication when used in conjunction with SMM.
Collaborative Corner: Self-Reflection
You may want to start your self-reflection with the following types of questions:
- What message am I sending?
- Who am I trying to convince and why?
- Is the purpose of my communication to achieve a group goal or a personal one?
- Am I open to the other ideas presented?
- How do I want my message received, or how was my message received?
Barriers to professional and collaborative success
By Cindy Mathena
Just as enablers or opportunities have been outlined in the literature as being necessary for success, some barriers exist as well. Many are obvious and include professional cultures promoting silos or stereotypes, use of different language and terminology, accreditors, and a required prescribed curriculum.5,7 Students are educated as they always have been, in schools of nursing, colleges of social work, and departments of athletic training. One can walk into any hospital or medical facility and find that tribalism is still alive and well.13 Nurses are still holding nursing meetings, OTs still have their own department, and PTs are still working at their desks next to each other. This solo work commonly leads one to think of working in a silo. Socialization, communication, IPE, and IPCP are some of the more obvious solutions to this barrier.9,14
Collaboration by the health care team can come at a cost and is difficult to achieve in a hierarchical team where some are seen as the leaders (physicians) and others as the team. A large number of studies validate the presence of professional stereotypes and cultures in the health care workplace.9,13,14 Many argue the solution to silos rests on the shoulders of the educational institution. Learning environments must be created that encourage real-life scenarios where students can learn the complexities of communication and problem solving with other professionals and as a team.
Accreditation requirements can be another barrier, though it should be pointed out that accreditors are also in a position to enable IPE. In the same way we see health care professionals working in a silo, accrediting agencies that certify educational institutions and programs have also historically worked alone. Standards for accreditation are often so prescriptive that little room is left in the curriculum to explore the roles and language of other professionals. Several studies cite limitations in curricula focused on discipline-specific skills and knowledge as a barrier to IPE. Because curricula are often well defined by professional accreditors, integrating other professions and competencies can be challenging.10,15 If universities and institutions play a primary role in the integration of IPCP into the preparation of students in health care, accreditors may have the biggest opportunity to create impactful IPE. It has been suggested that this would include an intersection of accreditors with overlapping standards.
Accreditors occupy a unique position, working within and across professions and health care delivery settings to promote interprofessional collaboration in education and care. Those who work within individual health professions and those accreditors working in different health care delivery domains should look to cross professional and delivery divides for more integrated approaches to the evaluation and regulation of education and clinical practice.15(p2)
Inconsistent and varying terminologies have been recognized as a barrier to IPCP and IPE. In the authors' experience, we have encountered students across health care professions who claim this to be the most significant barrier to IPCP in the health care setting. And while the terminologies used by each discipline may widely vary, our students state that it is important to begin discussions about these differences in the classroom.
Separate to this conversation about terminology is the need to understand that the interpretation of IPCP and IPE may vary by discipline. One study found that nurses and physicians in the operating room defined collaboration very differently. Nurses interpreted it to mean influencing team decisions, whereas physicians interpreted it as meaning their directions would be followed by the other disciplines on the team.16
Additional barriers to IPE implementation were noted in a study of nursing and medical students' perceptions of enablers and barriers. Those barriers included varying knowledge levels, low mutual respect between professions, and capacity and legal issues.7
Create an effective health care team
By K. Michelle Knewstep-Watkins, C. Michelle Longley, and Meghan M. Scanlon
Interprofessional Team Composition
Creating a highly effective health care team is rarely as simple as assembling a group of providers who are knowledgeable and experienced in their clinical practice. Commonly, the group members who will become a health care team are diverse with regard to knowledge, experience, values, and expectations. These differences can present challenges in aligning the team toward a common purpose and accepted processes for meeting the goals.
In some cases, there is an established group of experienced health care providers who have been working together to meet patient needs. These providers may have worked this way for decades, shared many experiences, developed their professional identities in relation to one another, and developed long-standing meaningful friendships. It is critical to recognize that the group may be diverse in the number of years of experience and years working together, which can mean there are established roles, routines, and habits well beyond the simple norms of a scope of practice. However, this does not necessarily mean that these health care providers are a high-functioning team. Similarly, other groups may have a majority of entry-level providers or providers who are new to the group or to serving a particular population, but these characteristics do not necessarily imply that they are a poorly functioning team.
A health care team is effective when all team members understand their role as part of the team as well as the roles and areas of expertise of other team members. One's role on a health care team should not be dictated wholly by profession. For example, patient safety is not solely the responsibility or role of nurses; instead, it is recognized as a shared role. However, it is important to recognize the recommendation of a dietitian in the creation of a patient's nutritional intake, because the dietitian is the professional with the greatest content knowledge in this area, even if other providers have an understanding of nutrition. See chapter 4 for a review of the evidence highlighting the impact of years of experience on IPE and IPCP.
Collaborative workplace environments are routinely associated with improved patient outcomes due to effective workflows and synergistic relationships. Even with shared goals and collaborative relationships, such environments require intentionality. Conflict is an inevitable part of working in teams and stems from individual, contextual, and intrapersonal characteristics that can significantly impair team cohesion and objectives.10 It is important for team participants and leaders to be familiar with sources of group conflict and implement strategies to resolve conflict effectively.
It is also valuable to recognize that teaming in a health care organization occurs on many levels. A team is defined as a group of people who assemble to achieve a common goal, which can occur in any organization regardless of size or complexity. Thus, health care organizations are composed of many layers of teams. The organization as a whole is a team, and additional levels of health care teams are nested within the organization to address cascading goals of the central goal. A medical center may also have diagnosis-centered service areas, such as orthopedics, which are teams within the organization. Additionally, formal teams can assemble to meet a specific need, such as a patient education committee, or informal teams may emerge organically in order to collaborate and address a concern.
Collaborative Corner: Sources of Conflict
Conflict can arise from individual characteristics, contextual factors, or intrapersonal conditions.11
- Individual characteristics—Individual team members enter group settings from different backgrounds with individualized values, opinions, and experiences that lead to assumptions about patient care needs and how to meet them.
- Contextual factors—Situations in which roles and responsibilities are unclear or group goals lack clarity can cause stress and conflict, particularly when combined with fast-paced environments, unpredictability, or high-stakes outcomes.
- Intrapersonal conditions—Conflict is common in circumstances of actual or perceived hierarchical relationships, inconsistent team membership and participation, or limited member or group accountability.
What methods or activities might assist in identifying and addressing individual characteristics, contextual factors, and intrapersonal conditions that contribute to conflict?
Foundation of IPE teaching and learning
By Joy Doll, Anthony Breitbach, and Kathrin Eliot
Scanning the literature on IPE and IPCP quickly reveals that diversity and context dictate the methods of delivery, whether in the academic or clinical environment. IPE and IPCP are not delivered in a one-size-fits-all approach; rather, they challenge educators to consider the learning environment, learning outcomes, and delivery context. For example, in the case study at the beginning of the chapter, IPE was accomplished by faculty champions passionate about the approach, but a clear plan was not in place when institutional support for IPE expanded. However, examples of best practice exist at many academic and clinical institutions. Chapter 1 lends credibility to IPCP regarding benefits to systems, procedures, and health outcomes; however, there remains a gap in the research on how IPE should be implemented.10 Although the lack of a clear road map results in a challenging ambiguity, that same ambiguity offers extensive opportunity to innovate and engage in creative approaches to advance both IPE and IPCP.
As discussed by Masten and colleagues, the road map to IPE is more about implementing culture change than simply taking an educational approach.11 It requires leaders and educators to consider cultural context as a driver for the design and implementation of IPE, which has been presented as a best practice and a deliberate design approach.4Masten and colleagues describe these cultural changes following 5 stages (figure 2.2):
- Stage 1: Awakening—The process of recognizing the value and importance of IPE begins.
- Stage 2: Giving lip service—Leaders and educators move beyond talking about IPE to implementing structures to support it, like faculty time and reward.
- Stage 3: Parallel play—Pockets of IPE exist but are often not institutionalized.
- Stage 4: Group play—IPE curriculum advances, with administrators recognizing the challenges and faculty champions receiving support to move IPE forward.
- Stage 5: Cultural transformation—IPE is being implemented well and is recognized by the wider university.11
Figure 2.2 Stages of IPE development.
This approach provides a road map for the stages of cultural transformation necessary to make IPE a sustained reality (for more on sustainability, see chapter 8). Despite the lack of clear evidence for an ideal IPE curriculum, the literature on teamwork and team science provides extensive support to pedagogical approaches. The reality remains that attitudes, behaviors, and skills that elicit successful IPCP do not require a clear end point of accomplishment or competence; rather, they require educators to prepare students for an ambiguous and unclear journey.13 This chapter provides a foundation to prepare learners (e.g., students, residents, fellows, clinicians, faculty) to gain the attitudes, behaviors, and skills to negotiate the contemporary health care landscape that is keenly focused on population health and societal needs.
Health care is a team sport
By Jordan Hamson-Utley
Health care is a team sport. Just as sport requires athleticism and sport-specific skills operating in synergy toward a goal, health care teams require captains, diverse skill sets, and coordination to improve a patient's health. In basketball, could a team of only point guards beat a championship team? This might be the health care equivalent of a team of only PTs providing care for a patient after a stroke, for example. Additionally, IPCP is essential for health care teams to achieve patient care goals. Each position on a team requires a unique set of skills; without a point guard, a basketball team would lack leadership, ball vision, communication, and a 3-point scoring threat. Similarly, without a case lead, a care team would lack leadership, planning, communication, and an opportunity to win by providing the best patient care possible.
Graduating team-ready health care professionals requires seasoned educators, those who are experts in best practices not only in the classroom but also in IPE facilitation. As a result of limited experience in IPE facilitation, many educators are slowing the adoption of IPE1 and potentially limiting the capacity of graduates to be ready to practice in a contemporary workplace. Literature to date is limited (but growing) in the area of faculty development for IPE, and existing research is not adequate to consider any method a best practice.2 However, promising findings across existing methodologies indicate the value of modeling IPE knowledge, skills, and attitudes (KSAs); group work; reflection; and appreciation of diversity.1
Educator development is a critical component in the effective delivery of IPE. For an interprofessional team to achieve its purpose, it must capitalize on the diverse knowledge and skills of the team. Delivering educator training in a collaborative framework affords exposure to teammates that promotes learning about each other, from each other, and with each other to devise strategies and solve problems related to classroom delivery or team-based patient care. The literature has established that continuing education that isolates health care professions prevents clinicians from developing collaborative capacities that meet the challenges of today's workplace.3,4 Programs that deliver learning using a teaming approach are best positioned to benefit from the role models and networks that are built into this approach. Faculty and clinicians who are expected to engage in IPE and the team-based learning of future clinicians must be supported with the knowledge and skills necessary to design and facilitate IPE.5
Communication strategies for interprofessional teams
By Dee M. Lance and Kim C. McCullough
General Communication Strategies
The goal of interprofessional teams is to offer patients effective and efficient treatment, and communication is a factor that influences the ability to meet that goal. Klinzing and Klinzing11 have identified some internal and external forces that interfere with the ability to engage in conversations or meetings:
- The mind processes words faster than they can be spoken, which can result in the formulation of responses before the message has been delivered.
- As people try to multitask, they experience divided attention, which can interfere with the ability to sustain attention during meetings.
- Environmental distractors, such as cell phones, noise in the hall, and shuffling feet, can interrupt attention.
If we allow things to compete for our attention when we are in a meeting, then we stop being communication collaborators.
Communication is a complex process, and both speakers and listeners carry responsibility for success. We have identified 9 actions (modified from Seery)20 that can support interprofessional teams in their communication efforts.
1. Use Engaged Listening
We have all experienced talking to people and knowing they were not listening. The listeners may be physically distracted, checking their watch or looking at their phone. They may appear distracted, and it is evident they are thinking about something other than what you are saying.
Engaged listening is required for effective communication, and it involves actually hearing and trying to understand what the speaker intends for you to understand. When listening, you can gain clarification by asking questions or rephrasing what you are hearing so that you're sure you fully understand the message as intended. Lake and her colleagues6 remind us that listeners share responsibility for ensuring they have an accurate and complete understanding of the message. They suggest the following techniques for active listening:
- Resolve differences between verbal and nonverbal messages.
- Reflect your feelings about what is being said.
- Ask clarification questions.
- Restate the speaker's message.
Using these techniques helps make communication a process that is a partnership between speaker and listener.
2. Use Nonverbal Communication
As stated previously, the words we select for the sentences we say make up only 7% of the message being conveyed. For both speaker and listener, the conscious use of proxemics, kinesthetics, facial expression and eye behavior, and paralinguistics can reduce miscommunications. For example, your body language should help convey your words and should indicate your openness to the message being sent. Other nonverbal communication acts, such as standing or sitting (proxemics), hand gestures (kinesthetics), eye contact (facial expression and eye behavior), and voice tone (paralinguistics), can enhance communication. For example, a team member may be more likely to speak openly if you are relaxed, have a friendly tone, and use an open posture with uncrossed legs and arms. Eye contact is also important; too much can be intimidating and too little can indicate you are nervous or disengaged. Conscious use of nonverbal cues can help counteract some of the professional, cultural, and linguistic differences you are likely to encounter on interprofessional teams. You can also use your understanding of nonverbal cues to interpret how other team members are feeling.
3. Be Concise and Clear
Team members' time is important, so you should be as concise as possible. Understanding the purpose of your interaction can help you stay focused and convey only the relevant information, which in turn helps the team achieve its common goal efficiently. You should not sacrifice clarity for conciseness, however. Be mindful of shared meaning; group diversity (e.g., professional, cultural, dialectical) could make jargon, professional acronyms, and colloquialisms problematic. Failure to be both concise and clear can cause frustration and confusion.
4. Be Personable
Everyone likes to work with someone who is pleasant, agreeable, and kind. These are some of the characteristics that could be considered personable. Using both verbal and nonverbal communication can help convey information about yourself. This can be as simple as smiling and nodding when you agree with what is being said, managing your tone so that passion does not sound like aggression, allowing others to state their opinion first so that you appear receptive to other ideas, or adding a personal message to an email so that your communication is less abrupt.
5. Speak With Confidence
When you convey to other team members that you are up to the task, then effective communication can occur. If you sound tentative about your contribution to the team, the team will be cautious about your ability to help meet the goal. Using nonverbal cues such as tone and stance can help portray confidence. You should also listen to the message others are communicating and then use engaged listening to seek clarification.
6. Show Empathy
Empathy, the ability to take the perspective of another person or to understand what someone is feeling, is a foundational skill for successful interactions. You do not have to agree with what people are saying to show that you appreciate their perspective. By saying to your team members, “I understand where you are coming from,” you let them know that you have heard their message. Remember that people from low-context and high-context cultures will react differently to disagreements, so use other tools to ensure relationships among group members stay intact.
7. Stay Open-Minded
We have discussed cultural, dialectical, and gender differences, all of which can influence shared meaning, relationships, and decision making. Using all of your tools to project openness to others' opinions and ideas is necessary for honest and effective communication.
8. Give and Receive Feedback
When you ask for clarification or restate something that has been said, you are providing feedback about your understanding and potentially about the effectiveness of the interaction. This is an essential skill for communication and for the interprofessional team to be efficient and effective. There are other types of devices as well, such as praising someone's presentation or providing supportive, constructive feedback that can strengthen any team. How you give and receive feedback can affect team morale, so having a handle on the cultural differences within the group can help you frame your questions and feedback.
9. Consider the Medium
A large part of figuring out the medium (e.g., oral, written, electronic) for any communication is considering the audience and purpose. Remember, when contemplating a written format, only a small portion of any attempt to communicate is conveyed by the words selected. Sensitive information may best be handled in person. Some communication devices, such as humor and sarcasm, use paralinguistic features and can fall flat when using written language. Additionally, when selecting a communication medium, careful thought should be given to any content that is sensitive or confidential.
Lake and colleagues6 suggest that structured reflection is useful to monitor and increase self-awareness as you practice communication techniques within your interprofessional team. Self-reflection can take the form of journaling and checklists before or after meetings and interactions. Choosing good communication strategies, consciously using them in conversations and meetings, and evaluating both your successes and failures is important for your individual success as well as for doing your part to ensure that the interprofessional team is effective and efficient.
EBP of Teamship: Closed-Loop Communication
Closed-loop communication (CLC) is a well-known team communication technique that has been studied as a mechanism for providing feedback in health care settings when performing collaborative tasks. It is often used during medical procedures and is adaptable for other health care teams. CLC consists of 3 steps:
- A team member calls out an observation or message.
- The second team member confirms that the message was received.
- The first team member confirms that original message was understood correctly.
For example, during a team meeting, a nurse states that the patient is NPO. The PT on the team confirms that the patient cannot be given any food or liquids by mouth. The nurse confirms by stating, “That is correct, the patient cannot be given any food or drink even if the patient requests it.”
In a case study, Johnson and colleagues21 investigated CLC along with two other communication techniques, shared mental model (SMM) and mutual trust (MT). SMM is based on the notion that, over time, team members develop a common context that facilitates understanding and the prediction of outcomes. MT is based on the shared belief that team members will do what they are supposed to do and that their actions will protect the team. The authors found that CLC was most helpful to team communication when used in conjunction with SMM.
Collaborative Corner: Self-Reflection
You may want to start your self-reflection with the following types of questions:
- What message am I sending?
- Who am I trying to convince and why?
- Is the purpose of my communication to achieve a group goal or a personal one?
- Am I open to the other ideas presented?
- How do I want my message received, or how was my message received?
Barriers to professional and collaborative success
By Cindy Mathena
Just as enablers or opportunities have been outlined in the literature as being necessary for success, some barriers exist as well. Many are obvious and include professional cultures promoting silos or stereotypes, use of different language and terminology, accreditors, and a required prescribed curriculum.5,7 Students are educated as they always have been, in schools of nursing, colleges of social work, and departments of athletic training. One can walk into any hospital or medical facility and find that tribalism is still alive and well.13 Nurses are still holding nursing meetings, OTs still have their own department, and PTs are still working at their desks next to each other. This solo work commonly leads one to think of working in a silo. Socialization, communication, IPE, and IPCP are some of the more obvious solutions to this barrier.9,14
Collaboration by the health care team can come at a cost and is difficult to achieve in a hierarchical team where some are seen as the leaders (physicians) and others as the team. A large number of studies validate the presence of professional stereotypes and cultures in the health care workplace.9,13,14 Many argue the solution to silos rests on the shoulders of the educational institution. Learning environments must be created that encourage real-life scenarios where students can learn the complexities of communication and problem solving with other professionals and as a team.
Accreditation requirements can be another barrier, though it should be pointed out that accreditors are also in a position to enable IPE. In the same way we see health care professionals working in a silo, accrediting agencies that certify educational institutions and programs have also historically worked alone. Standards for accreditation are often so prescriptive that little room is left in the curriculum to explore the roles and language of other professionals. Several studies cite limitations in curricula focused on discipline-specific skills and knowledge as a barrier to IPE. Because curricula are often well defined by professional accreditors, integrating other professions and competencies can be challenging.10,15 If universities and institutions play a primary role in the integration of IPCP into the preparation of students in health care, accreditors may have the biggest opportunity to create impactful IPE. It has been suggested that this would include an intersection of accreditors with overlapping standards.
Accreditors occupy a unique position, working within and across professions and health care delivery settings to promote interprofessional collaboration in education and care. Those who work within individual health professions and those accreditors working in different health care delivery domains should look to cross professional and delivery divides for more integrated approaches to the evaluation and regulation of education and clinical practice.15(p2)
Inconsistent and varying terminologies have been recognized as a barrier to IPCP and IPE. In the authors' experience, we have encountered students across health care professions who claim this to be the most significant barrier to IPCP in the health care setting. And while the terminologies used by each discipline may widely vary, our students state that it is important to begin discussions about these differences in the classroom.
Separate to this conversation about terminology is the need to understand that the interpretation of IPCP and IPE may vary by discipline. One study found that nurses and physicians in the operating room defined collaboration very differently. Nurses interpreted it to mean influencing team decisions, whereas physicians interpreted it as meaning their directions would be followed by the other disciplines on the team.16
Additional barriers to IPE implementation were noted in a study of nursing and medical students' perceptions of enablers and barriers. Those barriers included varying knowledge levels, low mutual respect between professions, and capacity and legal issues.7
Create an effective health care team
By K. Michelle Knewstep-Watkins, C. Michelle Longley, and Meghan M. Scanlon
Interprofessional Team Composition
Creating a highly effective health care team is rarely as simple as assembling a group of providers who are knowledgeable and experienced in their clinical practice. Commonly, the group members who will become a health care team are diverse with regard to knowledge, experience, values, and expectations. These differences can present challenges in aligning the team toward a common purpose and accepted processes for meeting the goals.
In some cases, there is an established group of experienced health care providers who have been working together to meet patient needs. These providers may have worked this way for decades, shared many experiences, developed their professional identities in relation to one another, and developed long-standing meaningful friendships. It is critical to recognize that the group may be diverse in the number of years of experience and years working together, which can mean there are established roles, routines, and habits well beyond the simple norms of a scope of practice. However, this does not necessarily mean that these health care providers are a high-functioning team. Similarly, other groups may have a majority of entry-level providers or providers who are new to the group or to serving a particular population, but these characteristics do not necessarily imply that they are a poorly functioning team.
A health care team is effective when all team members understand their role as part of the team as well as the roles and areas of expertise of other team members. One's role on a health care team should not be dictated wholly by profession. For example, patient safety is not solely the responsibility or role of nurses; instead, it is recognized as a shared role. However, it is important to recognize the recommendation of a dietitian in the creation of a patient's nutritional intake, because the dietitian is the professional with the greatest content knowledge in this area, even if other providers have an understanding of nutrition. See chapter 4 for a review of the evidence highlighting the impact of years of experience on IPE and IPCP.
Collaborative workplace environments are routinely associated with improved patient outcomes due to effective workflows and synergistic relationships. Even with shared goals and collaborative relationships, such environments require intentionality. Conflict is an inevitable part of working in teams and stems from individual, contextual, and intrapersonal characteristics that can significantly impair team cohesion and objectives.10 It is important for team participants and leaders to be familiar with sources of group conflict and implement strategies to resolve conflict effectively.
It is also valuable to recognize that teaming in a health care organization occurs on many levels. A team is defined as a group of people who assemble to achieve a common goal, which can occur in any organization regardless of size or complexity. Thus, health care organizations are composed of many layers of teams. The organization as a whole is a team, and additional levels of health care teams are nested within the organization to address cascading goals of the central goal. A medical center may also have diagnosis-centered service areas, such as orthopedics, which are teams within the organization. Additionally, formal teams can assemble to meet a specific need, such as a patient education committee, or informal teams may emerge organically in order to collaborate and address a concern.
Collaborative Corner: Sources of Conflict
Conflict can arise from individual characteristics, contextual factors, or intrapersonal conditions.11
- Individual characteristics—Individual team members enter group settings from different backgrounds with individualized values, opinions, and experiences that lead to assumptions about patient care needs and how to meet them.
- Contextual factors—Situations in which roles and responsibilities are unclear or group goals lack clarity can cause stress and conflict, particularly when combined with fast-paced environments, unpredictability, or high-stakes outcomes.
- Intrapersonal conditions—Conflict is common in circumstances of actual or perceived hierarchical relationships, inconsistent team membership and participation, or limited member or group accountability.
What methods or activities might assist in identifying and addressing individual characteristics, contextual factors, and intrapersonal conditions that contribute to conflict?
Foundation of IPE teaching and learning
By Joy Doll, Anthony Breitbach, and Kathrin Eliot
Scanning the literature on IPE and IPCP quickly reveals that diversity and context dictate the methods of delivery, whether in the academic or clinical environment. IPE and IPCP are not delivered in a one-size-fits-all approach; rather, they challenge educators to consider the learning environment, learning outcomes, and delivery context. For example, in the case study at the beginning of the chapter, IPE was accomplished by faculty champions passionate about the approach, but a clear plan was not in place when institutional support for IPE expanded. However, examples of best practice exist at many academic and clinical institutions. Chapter 1 lends credibility to IPCP regarding benefits to systems, procedures, and health outcomes; however, there remains a gap in the research on how IPE should be implemented.10 Although the lack of a clear road map results in a challenging ambiguity, that same ambiguity offers extensive opportunity to innovate and engage in creative approaches to advance both IPE and IPCP.
As discussed by Masten and colleagues, the road map to IPE is more about implementing culture change than simply taking an educational approach.11 It requires leaders and educators to consider cultural context as a driver for the design and implementation of IPE, which has been presented as a best practice and a deliberate design approach.4Masten and colleagues describe these cultural changes following 5 stages (figure 2.2):
- Stage 1: Awakening—The process of recognizing the value and importance of IPE begins.
- Stage 2: Giving lip service—Leaders and educators move beyond talking about IPE to implementing structures to support it, like faculty time and reward.
- Stage 3: Parallel play—Pockets of IPE exist but are often not institutionalized.
- Stage 4: Group play—IPE curriculum advances, with administrators recognizing the challenges and faculty champions receiving support to move IPE forward.
- Stage 5: Cultural transformation—IPE is being implemented well and is recognized by the wider university.11
Figure 2.2 Stages of IPE development.
This approach provides a road map for the stages of cultural transformation necessary to make IPE a sustained reality (for more on sustainability, see chapter 8). Despite the lack of clear evidence for an ideal IPE curriculum, the literature on teamwork and team science provides extensive support to pedagogical approaches. The reality remains that attitudes, behaviors, and skills that elicit successful IPCP do not require a clear end point of accomplishment or competence; rather, they require educators to prepare students for an ambiguous and unclear journey.13 This chapter provides a foundation to prepare learners (e.g., students, residents, fellows, clinicians, faculty) to gain the attitudes, behaviors, and skills to negotiate the contemporary health care landscape that is keenly focused on population health and societal needs.
Health care is a team sport
By Jordan Hamson-Utley
Health care is a team sport. Just as sport requires athleticism and sport-specific skills operating in synergy toward a goal, health care teams require captains, diverse skill sets, and coordination to improve a patient's health. In basketball, could a team of only point guards beat a championship team? This might be the health care equivalent of a team of only PTs providing care for a patient after a stroke, for example. Additionally, IPCP is essential for health care teams to achieve patient care goals. Each position on a team requires a unique set of skills; without a point guard, a basketball team would lack leadership, ball vision, communication, and a 3-point scoring threat. Similarly, without a case lead, a care team would lack leadership, planning, communication, and an opportunity to win by providing the best patient care possible.
Graduating team-ready health care professionals requires seasoned educators, those who are experts in best practices not only in the classroom but also in IPE facilitation. As a result of limited experience in IPE facilitation, many educators are slowing the adoption of IPE1 and potentially limiting the capacity of graduates to be ready to practice in a contemporary workplace. Literature to date is limited (but growing) in the area of faculty development for IPE, and existing research is not adequate to consider any method a best practice.2 However, promising findings across existing methodologies indicate the value of modeling IPE knowledge, skills, and attitudes (KSAs); group work; reflection; and appreciation of diversity.1
Educator development is a critical component in the effective delivery of IPE. For an interprofessional team to achieve its purpose, it must capitalize on the diverse knowledge and skills of the team. Delivering educator training in a collaborative framework affords exposure to teammates that promotes learning about each other, from each other, and with each other to devise strategies and solve problems related to classroom delivery or team-based patient care. The literature has established that continuing education that isolates health care professions prevents clinicians from developing collaborative capacities that meet the challenges of today's workplace.3,4 Programs that deliver learning using a teaming approach are best positioned to benefit from the role models and networks that are built into this approach. Faculty and clinicians who are expected to engage in IPE and the team-based learning of future clinicians must be supported with the knowledge and skills necessary to design and facilitate IPE.5
Communication strategies for interprofessional teams
By Dee M. Lance and Kim C. McCullough
General Communication Strategies
The goal of interprofessional teams is to offer patients effective and efficient treatment, and communication is a factor that influences the ability to meet that goal. Klinzing and Klinzing11 have identified some internal and external forces that interfere with the ability to engage in conversations or meetings:
- The mind processes words faster than they can be spoken, which can result in the formulation of responses before the message has been delivered.
- As people try to multitask, they experience divided attention, which can interfere with the ability to sustain attention during meetings.
- Environmental distractors, such as cell phones, noise in the hall, and shuffling feet, can interrupt attention.
If we allow things to compete for our attention when we are in a meeting, then we stop being communication collaborators.
Communication is a complex process, and both speakers and listeners carry responsibility for success. We have identified 9 actions (modified from Seery)20 that can support interprofessional teams in their communication efforts.
1. Use Engaged Listening
We have all experienced talking to people and knowing they were not listening. The listeners may be physically distracted, checking their watch or looking at their phone. They may appear distracted, and it is evident they are thinking about something other than what you are saying.
Engaged listening is required for effective communication, and it involves actually hearing and trying to understand what the speaker intends for you to understand. When listening, you can gain clarification by asking questions or rephrasing what you are hearing so that you're sure you fully understand the message as intended. Lake and her colleagues6 remind us that listeners share responsibility for ensuring they have an accurate and complete understanding of the message. They suggest the following techniques for active listening:
- Resolve differences between verbal and nonverbal messages.
- Reflect your feelings about what is being said.
- Ask clarification questions.
- Restate the speaker's message.
Using these techniques helps make communication a process that is a partnership between speaker and listener.
2. Use Nonverbal Communication
As stated previously, the words we select for the sentences we say make up only 7% of the message being conveyed. For both speaker and listener, the conscious use of proxemics, kinesthetics, facial expression and eye behavior, and paralinguistics can reduce miscommunications. For example, your body language should help convey your words and should indicate your openness to the message being sent. Other nonverbal communication acts, such as standing or sitting (proxemics), hand gestures (kinesthetics), eye contact (facial expression and eye behavior), and voice tone (paralinguistics), can enhance communication. For example, a team member may be more likely to speak openly if you are relaxed, have a friendly tone, and use an open posture with uncrossed legs and arms. Eye contact is also important; too much can be intimidating and too little can indicate you are nervous or disengaged. Conscious use of nonverbal cues can help counteract some of the professional, cultural, and linguistic differences you are likely to encounter on interprofessional teams. You can also use your understanding of nonverbal cues to interpret how other team members are feeling.
3. Be Concise and Clear
Team members' time is important, so you should be as concise as possible. Understanding the purpose of your interaction can help you stay focused and convey only the relevant information, which in turn helps the team achieve its common goal efficiently. You should not sacrifice clarity for conciseness, however. Be mindful of shared meaning; group diversity (e.g., professional, cultural, dialectical) could make jargon, professional acronyms, and colloquialisms problematic. Failure to be both concise and clear can cause frustration and confusion.
4. Be Personable
Everyone likes to work with someone who is pleasant, agreeable, and kind. These are some of the characteristics that could be considered personable. Using both verbal and nonverbal communication can help convey information about yourself. This can be as simple as smiling and nodding when you agree with what is being said, managing your tone so that passion does not sound like aggression, allowing others to state their opinion first so that you appear receptive to other ideas, or adding a personal message to an email so that your communication is less abrupt.
5. Speak With Confidence
When you convey to other team members that you are up to the task, then effective communication can occur. If you sound tentative about your contribution to the team, the team will be cautious about your ability to help meet the goal. Using nonverbal cues such as tone and stance can help portray confidence. You should also listen to the message others are communicating and then use engaged listening to seek clarification.
6. Show Empathy
Empathy, the ability to take the perspective of another person or to understand what someone is feeling, is a foundational skill for successful interactions. You do not have to agree with what people are saying to show that you appreciate their perspective. By saying to your team members, “I understand where you are coming from,” you let them know that you have heard their message. Remember that people from low-context and high-context cultures will react differently to disagreements, so use other tools to ensure relationships among group members stay intact.
7. Stay Open-Minded
We have discussed cultural, dialectical, and gender differences, all of which can influence shared meaning, relationships, and decision making. Using all of your tools to project openness to others' opinions and ideas is necessary for honest and effective communication.
8. Give and Receive Feedback
When you ask for clarification or restate something that has been said, you are providing feedback about your understanding and potentially about the effectiveness of the interaction. This is an essential skill for communication and for the interprofessional team to be efficient and effective. There are other types of devices as well, such as praising someone's presentation or providing supportive, constructive feedback that can strengthen any team. How you give and receive feedback can affect team morale, so having a handle on the cultural differences within the group can help you frame your questions and feedback.
9. Consider the Medium
A large part of figuring out the medium (e.g., oral, written, electronic) for any communication is considering the audience and purpose. Remember, when contemplating a written format, only a small portion of any attempt to communicate is conveyed by the words selected. Sensitive information may best be handled in person. Some communication devices, such as humor and sarcasm, use paralinguistic features and can fall flat when using written language. Additionally, when selecting a communication medium, careful thought should be given to any content that is sensitive or confidential.
Lake and colleagues6 suggest that structured reflection is useful to monitor and increase self-awareness as you practice communication techniques within your interprofessional team. Self-reflection can take the form of journaling and checklists before or after meetings and interactions. Choosing good communication strategies, consciously using them in conversations and meetings, and evaluating both your successes and failures is important for your individual success as well as for doing your part to ensure that the interprofessional team is effective and efficient.
EBP of Teamship: Closed-Loop Communication
Closed-loop communication (CLC) is a well-known team communication technique that has been studied as a mechanism for providing feedback in health care settings when performing collaborative tasks. It is often used during medical procedures and is adaptable for other health care teams. CLC consists of 3 steps:
- A team member calls out an observation or message.
- The second team member confirms that the message was received.
- The first team member confirms that original message was understood correctly.
For example, during a team meeting, a nurse states that the patient is NPO. The PT on the team confirms that the patient cannot be given any food or liquids by mouth. The nurse confirms by stating, “That is correct, the patient cannot be given any food or drink even if the patient requests it.”
In a case study, Johnson and colleagues21 investigated CLC along with two other communication techniques, shared mental model (SMM) and mutual trust (MT). SMM is based on the notion that, over time, team members develop a common context that facilitates understanding and the prediction of outcomes. MT is based on the shared belief that team members will do what they are supposed to do and that their actions will protect the team. The authors found that CLC was most helpful to team communication when used in conjunction with SMM.
Collaborative Corner: Self-Reflection
You may want to start your self-reflection with the following types of questions:
- What message am I sending?
- Who am I trying to convince and why?
- Is the purpose of my communication to achieve a group goal or a personal one?
- Am I open to the other ideas presented?
- How do I want my message received, or how was my message received?
Barriers to professional and collaborative success
By Cindy Mathena
Just as enablers or opportunities have been outlined in the literature as being necessary for success, some barriers exist as well. Many are obvious and include professional cultures promoting silos or stereotypes, use of different language and terminology, accreditors, and a required prescribed curriculum.5,7 Students are educated as they always have been, in schools of nursing, colleges of social work, and departments of athletic training. One can walk into any hospital or medical facility and find that tribalism is still alive and well.13 Nurses are still holding nursing meetings, OTs still have their own department, and PTs are still working at their desks next to each other. This solo work commonly leads one to think of working in a silo. Socialization, communication, IPE, and IPCP are some of the more obvious solutions to this barrier.9,14
Collaboration by the health care team can come at a cost and is difficult to achieve in a hierarchical team where some are seen as the leaders (physicians) and others as the team. A large number of studies validate the presence of professional stereotypes and cultures in the health care workplace.9,13,14 Many argue the solution to silos rests on the shoulders of the educational institution. Learning environments must be created that encourage real-life scenarios where students can learn the complexities of communication and problem solving with other professionals and as a team.
Accreditation requirements can be another barrier, though it should be pointed out that accreditors are also in a position to enable IPE. In the same way we see health care professionals working in a silo, accrediting agencies that certify educational institutions and programs have also historically worked alone. Standards for accreditation are often so prescriptive that little room is left in the curriculum to explore the roles and language of other professionals. Several studies cite limitations in curricula focused on discipline-specific skills and knowledge as a barrier to IPE. Because curricula are often well defined by professional accreditors, integrating other professions and competencies can be challenging.10,15 If universities and institutions play a primary role in the integration of IPCP into the preparation of students in health care, accreditors may have the biggest opportunity to create impactful IPE. It has been suggested that this would include an intersection of accreditors with overlapping standards.
Accreditors occupy a unique position, working within and across professions and health care delivery settings to promote interprofessional collaboration in education and care. Those who work within individual health professions and those accreditors working in different health care delivery domains should look to cross professional and delivery divides for more integrated approaches to the evaluation and regulation of education and clinical practice.15(p2)
Inconsistent and varying terminologies have been recognized as a barrier to IPCP and IPE. In the authors' experience, we have encountered students across health care professions who claim this to be the most significant barrier to IPCP in the health care setting. And while the terminologies used by each discipline may widely vary, our students state that it is important to begin discussions about these differences in the classroom.
Separate to this conversation about terminology is the need to understand that the interpretation of IPCP and IPE may vary by discipline. One study found that nurses and physicians in the operating room defined collaboration very differently. Nurses interpreted it to mean influencing team decisions, whereas physicians interpreted it as meaning their directions would be followed by the other disciplines on the team.16
Additional barriers to IPE implementation were noted in a study of nursing and medical students' perceptions of enablers and barriers. Those barriers included varying knowledge levels, low mutual respect between professions, and capacity and legal issues.7
Create an effective health care team
By K. Michelle Knewstep-Watkins, C. Michelle Longley, and Meghan M. Scanlon
Interprofessional Team Composition
Creating a highly effective health care team is rarely as simple as assembling a group of providers who are knowledgeable and experienced in their clinical practice. Commonly, the group members who will become a health care team are diverse with regard to knowledge, experience, values, and expectations. These differences can present challenges in aligning the team toward a common purpose and accepted processes for meeting the goals.
In some cases, there is an established group of experienced health care providers who have been working together to meet patient needs. These providers may have worked this way for decades, shared many experiences, developed their professional identities in relation to one another, and developed long-standing meaningful friendships. It is critical to recognize that the group may be diverse in the number of years of experience and years working together, which can mean there are established roles, routines, and habits well beyond the simple norms of a scope of practice. However, this does not necessarily mean that these health care providers are a high-functioning team. Similarly, other groups may have a majority of entry-level providers or providers who are new to the group or to serving a particular population, but these characteristics do not necessarily imply that they are a poorly functioning team.
A health care team is effective when all team members understand their role as part of the team as well as the roles and areas of expertise of other team members. One's role on a health care team should not be dictated wholly by profession. For example, patient safety is not solely the responsibility or role of nurses; instead, it is recognized as a shared role. However, it is important to recognize the recommendation of a dietitian in the creation of a patient's nutritional intake, because the dietitian is the professional with the greatest content knowledge in this area, even if other providers have an understanding of nutrition. See chapter 4 for a review of the evidence highlighting the impact of years of experience on IPE and IPCP.
Collaborative workplace environments are routinely associated with improved patient outcomes due to effective workflows and synergistic relationships. Even with shared goals and collaborative relationships, such environments require intentionality. Conflict is an inevitable part of working in teams and stems from individual, contextual, and intrapersonal characteristics that can significantly impair team cohesion and objectives.10 It is important for team participants and leaders to be familiar with sources of group conflict and implement strategies to resolve conflict effectively.
It is also valuable to recognize that teaming in a health care organization occurs on many levels. A team is defined as a group of people who assemble to achieve a common goal, which can occur in any organization regardless of size or complexity. Thus, health care organizations are composed of many layers of teams. The organization as a whole is a team, and additional levels of health care teams are nested within the organization to address cascading goals of the central goal. A medical center may also have diagnosis-centered service areas, such as orthopedics, which are teams within the organization. Additionally, formal teams can assemble to meet a specific need, such as a patient education committee, or informal teams may emerge organically in order to collaborate and address a concern.
Collaborative Corner: Sources of Conflict
Conflict can arise from individual characteristics, contextual factors, or intrapersonal conditions.11
- Individual characteristics—Individual team members enter group settings from different backgrounds with individualized values, opinions, and experiences that lead to assumptions about patient care needs and how to meet them.
- Contextual factors—Situations in which roles and responsibilities are unclear or group goals lack clarity can cause stress and conflict, particularly when combined with fast-paced environments, unpredictability, or high-stakes outcomes.
- Intrapersonal conditions—Conflict is common in circumstances of actual or perceived hierarchical relationships, inconsistent team membership and participation, or limited member or group accountability.
What methods or activities might assist in identifying and addressing individual characteristics, contextual factors, and intrapersonal conditions that contribute to conflict?
Foundation of IPE teaching and learning
By Joy Doll, Anthony Breitbach, and Kathrin Eliot
Scanning the literature on IPE and IPCP quickly reveals that diversity and context dictate the methods of delivery, whether in the academic or clinical environment. IPE and IPCP are not delivered in a one-size-fits-all approach; rather, they challenge educators to consider the learning environment, learning outcomes, and delivery context. For example, in the case study at the beginning of the chapter, IPE was accomplished by faculty champions passionate about the approach, but a clear plan was not in place when institutional support for IPE expanded. However, examples of best practice exist at many academic and clinical institutions. Chapter 1 lends credibility to IPCP regarding benefits to systems, procedures, and health outcomes; however, there remains a gap in the research on how IPE should be implemented.10 Although the lack of a clear road map results in a challenging ambiguity, that same ambiguity offers extensive opportunity to innovate and engage in creative approaches to advance both IPE and IPCP.
As discussed by Masten and colleagues, the road map to IPE is more about implementing culture change than simply taking an educational approach.11 It requires leaders and educators to consider cultural context as a driver for the design and implementation of IPE, which has been presented as a best practice and a deliberate design approach.4Masten and colleagues describe these cultural changes following 5 stages (figure 2.2):
- Stage 1: Awakening—The process of recognizing the value and importance of IPE begins.
- Stage 2: Giving lip service—Leaders and educators move beyond talking about IPE to implementing structures to support it, like faculty time and reward.
- Stage 3: Parallel play—Pockets of IPE exist but are often not institutionalized.
- Stage 4: Group play—IPE curriculum advances, with administrators recognizing the challenges and faculty champions receiving support to move IPE forward.
- Stage 5: Cultural transformation—IPE is being implemented well and is recognized by the wider university.11
Figure 2.2 Stages of IPE development.
This approach provides a road map for the stages of cultural transformation necessary to make IPE a sustained reality (for more on sustainability, see chapter 8). Despite the lack of clear evidence for an ideal IPE curriculum, the literature on teamwork and team science provides extensive support to pedagogical approaches. The reality remains that attitudes, behaviors, and skills that elicit successful IPCP do not require a clear end point of accomplishment or competence; rather, they require educators to prepare students for an ambiguous and unclear journey.13 This chapter provides a foundation to prepare learners (e.g., students, residents, fellows, clinicians, faculty) to gain the attitudes, behaviors, and skills to negotiate the contemporary health care landscape that is keenly focused on population health and societal needs.
Health care is a team sport
By Jordan Hamson-Utley
Health care is a team sport. Just as sport requires athleticism and sport-specific skills operating in synergy toward a goal, health care teams require captains, diverse skill sets, and coordination to improve a patient's health. In basketball, could a team of only point guards beat a championship team? This might be the health care equivalent of a team of only PTs providing care for a patient after a stroke, for example. Additionally, IPCP is essential for health care teams to achieve patient care goals. Each position on a team requires a unique set of skills; without a point guard, a basketball team would lack leadership, ball vision, communication, and a 3-point scoring threat. Similarly, without a case lead, a care team would lack leadership, planning, communication, and an opportunity to win by providing the best patient care possible.
Graduating team-ready health care professionals requires seasoned educators, those who are experts in best practices not only in the classroom but also in IPE facilitation. As a result of limited experience in IPE facilitation, many educators are slowing the adoption of IPE1 and potentially limiting the capacity of graduates to be ready to practice in a contemporary workplace. Literature to date is limited (but growing) in the area of faculty development for IPE, and existing research is not adequate to consider any method a best practice.2 However, promising findings across existing methodologies indicate the value of modeling IPE knowledge, skills, and attitudes (KSAs); group work; reflection; and appreciation of diversity.1
Educator development is a critical component in the effective delivery of IPE. For an interprofessional team to achieve its purpose, it must capitalize on the diverse knowledge and skills of the team. Delivering educator training in a collaborative framework affords exposure to teammates that promotes learning about each other, from each other, and with each other to devise strategies and solve problems related to classroom delivery or team-based patient care. The literature has established that continuing education that isolates health care professions prevents clinicians from developing collaborative capacities that meet the challenges of today's workplace.3,4 Programs that deliver learning using a teaming approach are best positioned to benefit from the role models and networks that are built into this approach. Faculty and clinicians who are expected to engage in IPE and the team-based learning of future clinicians must be supported with the knowledge and skills necessary to design and facilitate IPE.5
Communication strategies for interprofessional teams
By Dee M. Lance and Kim C. McCullough
General Communication Strategies
The goal of interprofessional teams is to offer patients effective and efficient treatment, and communication is a factor that influences the ability to meet that goal. Klinzing and Klinzing11 have identified some internal and external forces that interfere with the ability to engage in conversations or meetings:
- The mind processes words faster than they can be spoken, which can result in the formulation of responses before the message has been delivered.
- As people try to multitask, they experience divided attention, which can interfere with the ability to sustain attention during meetings.
- Environmental distractors, such as cell phones, noise in the hall, and shuffling feet, can interrupt attention.
If we allow things to compete for our attention when we are in a meeting, then we stop being communication collaborators.
Communication is a complex process, and both speakers and listeners carry responsibility for success. We have identified 9 actions (modified from Seery)20 that can support interprofessional teams in their communication efforts.
1. Use Engaged Listening
We have all experienced talking to people and knowing they were not listening. The listeners may be physically distracted, checking their watch or looking at their phone. They may appear distracted, and it is evident they are thinking about something other than what you are saying.
Engaged listening is required for effective communication, and it involves actually hearing and trying to understand what the speaker intends for you to understand. When listening, you can gain clarification by asking questions or rephrasing what you are hearing so that you're sure you fully understand the message as intended. Lake and her colleagues6 remind us that listeners share responsibility for ensuring they have an accurate and complete understanding of the message. They suggest the following techniques for active listening:
- Resolve differences between verbal and nonverbal messages.
- Reflect your feelings about what is being said.
- Ask clarification questions.
- Restate the speaker's message.
Using these techniques helps make communication a process that is a partnership between speaker and listener.
2. Use Nonverbal Communication
As stated previously, the words we select for the sentences we say make up only 7% of the message being conveyed. For both speaker and listener, the conscious use of proxemics, kinesthetics, facial expression and eye behavior, and paralinguistics can reduce miscommunications. For example, your body language should help convey your words and should indicate your openness to the message being sent. Other nonverbal communication acts, such as standing or sitting (proxemics), hand gestures (kinesthetics), eye contact (facial expression and eye behavior), and voice tone (paralinguistics), can enhance communication. For example, a team member may be more likely to speak openly if you are relaxed, have a friendly tone, and use an open posture with uncrossed legs and arms. Eye contact is also important; too much can be intimidating and too little can indicate you are nervous or disengaged. Conscious use of nonverbal cues can help counteract some of the professional, cultural, and linguistic differences you are likely to encounter on interprofessional teams. You can also use your understanding of nonverbal cues to interpret how other team members are feeling.
3. Be Concise and Clear
Team members' time is important, so you should be as concise as possible. Understanding the purpose of your interaction can help you stay focused and convey only the relevant information, which in turn helps the team achieve its common goal efficiently. You should not sacrifice clarity for conciseness, however. Be mindful of shared meaning; group diversity (e.g., professional, cultural, dialectical) could make jargon, professional acronyms, and colloquialisms problematic. Failure to be both concise and clear can cause frustration and confusion.
4. Be Personable
Everyone likes to work with someone who is pleasant, agreeable, and kind. These are some of the characteristics that could be considered personable. Using both verbal and nonverbal communication can help convey information about yourself. This can be as simple as smiling and nodding when you agree with what is being said, managing your tone so that passion does not sound like aggression, allowing others to state their opinion first so that you appear receptive to other ideas, or adding a personal message to an email so that your communication is less abrupt.
5. Speak With Confidence
When you convey to other team members that you are up to the task, then effective communication can occur. If you sound tentative about your contribution to the team, the team will be cautious about your ability to help meet the goal. Using nonverbal cues such as tone and stance can help portray confidence. You should also listen to the message others are communicating and then use engaged listening to seek clarification.
6. Show Empathy
Empathy, the ability to take the perspective of another person or to understand what someone is feeling, is a foundational skill for successful interactions. You do not have to agree with what people are saying to show that you appreciate their perspective. By saying to your team members, “I understand where you are coming from,” you let them know that you have heard their message. Remember that people from low-context and high-context cultures will react differently to disagreements, so use other tools to ensure relationships among group members stay intact.
7. Stay Open-Minded
We have discussed cultural, dialectical, and gender differences, all of which can influence shared meaning, relationships, and decision making. Using all of your tools to project openness to others' opinions and ideas is necessary for honest and effective communication.
8. Give and Receive Feedback
When you ask for clarification or restate something that has been said, you are providing feedback about your understanding and potentially about the effectiveness of the interaction. This is an essential skill for communication and for the interprofessional team to be efficient and effective. There are other types of devices as well, such as praising someone's presentation or providing supportive, constructive feedback that can strengthen any team. How you give and receive feedback can affect team morale, so having a handle on the cultural differences within the group can help you frame your questions and feedback.
9. Consider the Medium
A large part of figuring out the medium (e.g., oral, written, electronic) for any communication is considering the audience and purpose. Remember, when contemplating a written format, only a small portion of any attempt to communicate is conveyed by the words selected. Sensitive information may best be handled in person. Some communication devices, such as humor and sarcasm, use paralinguistic features and can fall flat when using written language. Additionally, when selecting a communication medium, careful thought should be given to any content that is sensitive or confidential.
Lake and colleagues6 suggest that structured reflection is useful to monitor and increase self-awareness as you practice communication techniques within your interprofessional team. Self-reflection can take the form of journaling and checklists before or after meetings and interactions. Choosing good communication strategies, consciously using them in conversations and meetings, and evaluating both your successes and failures is important for your individual success as well as for doing your part to ensure that the interprofessional team is effective and efficient.
EBP of Teamship: Closed-Loop Communication
Closed-loop communication (CLC) is a well-known team communication technique that has been studied as a mechanism for providing feedback in health care settings when performing collaborative tasks. It is often used during medical procedures and is adaptable for other health care teams. CLC consists of 3 steps:
- A team member calls out an observation or message.
- The second team member confirms that the message was received.
- The first team member confirms that original message was understood correctly.
For example, during a team meeting, a nurse states that the patient is NPO. The PT on the team confirms that the patient cannot be given any food or liquids by mouth. The nurse confirms by stating, “That is correct, the patient cannot be given any food or drink even if the patient requests it.”
In a case study, Johnson and colleagues21 investigated CLC along with two other communication techniques, shared mental model (SMM) and mutual trust (MT). SMM is based on the notion that, over time, team members develop a common context that facilitates understanding and the prediction of outcomes. MT is based on the shared belief that team members will do what they are supposed to do and that their actions will protect the team. The authors found that CLC was most helpful to team communication when used in conjunction with SMM.
Collaborative Corner: Self-Reflection
You may want to start your self-reflection with the following types of questions:
- What message am I sending?
- Who am I trying to convince and why?
- Is the purpose of my communication to achieve a group goal or a personal one?
- Am I open to the other ideas presented?
- How do I want my message received, or how was my message received?
Barriers to professional and collaborative success
By Cindy Mathena
Just as enablers or opportunities have been outlined in the literature as being necessary for success, some barriers exist as well. Many are obvious and include professional cultures promoting silos or stereotypes, use of different language and terminology, accreditors, and a required prescribed curriculum.5,7 Students are educated as they always have been, in schools of nursing, colleges of social work, and departments of athletic training. One can walk into any hospital or medical facility and find that tribalism is still alive and well.13 Nurses are still holding nursing meetings, OTs still have their own department, and PTs are still working at their desks next to each other. This solo work commonly leads one to think of working in a silo. Socialization, communication, IPE, and IPCP are some of the more obvious solutions to this barrier.9,14
Collaboration by the health care team can come at a cost and is difficult to achieve in a hierarchical team where some are seen as the leaders (physicians) and others as the team. A large number of studies validate the presence of professional stereotypes and cultures in the health care workplace.9,13,14 Many argue the solution to silos rests on the shoulders of the educational institution. Learning environments must be created that encourage real-life scenarios where students can learn the complexities of communication and problem solving with other professionals and as a team.
Accreditation requirements can be another barrier, though it should be pointed out that accreditors are also in a position to enable IPE. In the same way we see health care professionals working in a silo, accrediting agencies that certify educational institutions and programs have also historically worked alone. Standards for accreditation are often so prescriptive that little room is left in the curriculum to explore the roles and language of other professionals. Several studies cite limitations in curricula focused on discipline-specific skills and knowledge as a barrier to IPE. Because curricula are often well defined by professional accreditors, integrating other professions and competencies can be challenging.10,15 If universities and institutions play a primary role in the integration of IPCP into the preparation of students in health care, accreditors may have the biggest opportunity to create impactful IPE. It has been suggested that this would include an intersection of accreditors with overlapping standards.
Accreditors occupy a unique position, working within and across professions and health care delivery settings to promote interprofessional collaboration in education and care. Those who work within individual health professions and those accreditors working in different health care delivery domains should look to cross professional and delivery divides for more integrated approaches to the evaluation and regulation of education and clinical practice.15(p2)
Inconsistent and varying terminologies have been recognized as a barrier to IPCP and IPE. In the authors' experience, we have encountered students across health care professions who claim this to be the most significant barrier to IPCP in the health care setting. And while the terminologies used by each discipline may widely vary, our students state that it is important to begin discussions about these differences in the classroom.
Separate to this conversation about terminology is the need to understand that the interpretation of IPCP and IPE may vary by discipline. One study found that nurses and physicians in the operating room defined collaboration very differently. Nurses interpreted it to mean influencing team decisions, whereas physicians interpreted it as meaning their directions would be followed by the other disciplines on the team.16
Additional barriers to IPE implementation were noted in a study of nursing and medical students' perceptions of enablers and barriers. Those barriers included varying knowledge levels, low mutual respect between professions, and capacity and legal issues.7
Create an effective health care team
By K. Michelle Knewstep-Watkins, C. Michelle Longley, and Meghan M. Scanlon
Interprofessional Team Composition
Creating a highly effective health care team is rarely as simple as assembling a group of providers who are knowledgeable and experienced in their clinical practice. Commonly, the group members who will become a health care team are diverse with regard to knowledge, experience, values, and expectations. These differences can present challenges in aligning the team toward a common purpose and accepted processes for meeting the goals.
In some cases, there is an established group of experienced health care providers who have been working together to meet patient needs. These providers may have worked this way for decades, shared many experiences, developed their professional identities in relation to one another, and developed long-standing meaningful friendships. It is critical to recognize that the group may be diverse in the number of years of experience and years working together, which can mean there are established roles, routines, and habits well beyond the simple norms of a scope of practice. However, this does not necessarily mean that these health care providers are a high-functioning team. Similarly, other groups may have a majority of entry-level providers or providers who are new to the group or to serving a particular population, but these characteristics do not necessarily imply that they are a poorly functioning team.
A health care team is effective when all team members understand their role as part of the team as well as the roles and areas of expertise of other team members. One's role on a health care team should not be dictated wholly by profession. For example, patient safety is not solely the responsibility or role of nurses; instead, it is recognized as a shared role. However, it is important to recognize the recommendation of a dietitian in the creation of a patient's nutritional intake, because the dietitian is the professional with the greatest content knowledge in this area, even if other providers have an understanding of nutrition. See chapter 4 for a review of the evidence highlighting the impact of years of experience on IPE and IPCP.
Collaborative workplace environments are routinely associated with improved patient outcomes due to effective workflows and synergistic relationships. Even with shared goals and collaborative relationships, such environments require intentionality. Conflict is an inevitable part of working in teams and stems from individual, contextual, and intrapersonal characteristics that can significantly impair team cohesion and objectives.10 It is important for team participants and leaders to be familiar with sources of group conflict and implement strategies to resolve conflict effectively.
It is also valuable to recognize that teaming in a health care organization occurs on many levels. A team is defined as a group of people who assemble to achieve a common goal, which can occur in any organization regardless of size or complexity. Thus, health care organizations are composed of many layers of teams. The organization as a whole is a team, and additional levels of health care teams are nested within the organization to address cascading goals of the central goal. A medical center may also have diagnosis-centered service areas, such as orthopedics, which are teams within the organization. Additionally, formal teams can assemble to meet a specific need, such as a patient education committee, or informal teams may emerge organically in order to collaborate and address a concern.
Collaborative Corner: Sources of Conflict
Conflict can arise from individual characteristics, contextual factors, or intrapersonal conditions.11
- Individual characteristics—Individual team members enter group settings from different backgrounds with individualized values, opinions, and experiences that lead to assumptions about patient care needs and how to meet them.
- Contextual factors—Situations in which roles and responsibilities are unclear or group goals lack clarity can cause stress and conflict, particularly when combined with fast-paced environments, unpredictability, or high-stakes outcomes.
- Intrapersonal conditions—Conflict is common in circumstances of actual or perceived hierarchical relationships, inconsistent team membership and participation, or limited member or group accountability.
What methods or activities might assist in identifying and addressing individual characteristics, contextual factors, and intrapersonal conditions that contribute to conflict?
Foundation of IPE teaching and learning
By Joy Doll, Anthony Breitbach, and Kathrin Eliot
Scanning the literature on IPE and IPCP quickly reveals that diversity and context dictate the methods of delivery, whether in the academic or clinical environment. IPE and IPCP are not delivered in a one-size-fits-all approach; rather, they challenge educators to consider the learning environment, learning outcomes, and delivery context. For example, in the case study at the beginning of the chapter, IPE was accomplished by faculty champions passionate about the approach, but a clear plan was not in place when institutional support for IPE expanded. However, examples of best practice exist at many academic and clinical institutions. Chapter 1 lends credibility to IPCP regarding benefits to systems, procedures, and health outcomes; however, there remains a gap in the research on how IPE should be implemented.10 Although the lack of a clear road map results in a challenging ambiguity, that same ambiguity offers extensive opportunity to innovate and engage in creative approaches to advance both IPE and IPCP.
As discussed by Masten and colleagues, the road map to IPE is more about implementing culture change than simply taking an educational approach.11 It requires leaders and educators to consider cultural context as a driver for the design and implementation of IPE, which has been presented as a best practice and a deliberate design approach.4Masten and colleagues describe these cultural changes following 5 stages (figure 2.2):
- Stage 1: Awakening—The process of recognizing the value and importance of IPE begins.
- Stage 2: Giving lip service—Leaders and educators move beyond talking about IPE to implementing structures to support it, like faculty time and reward.
- Stage 3: Parallel play—Pockets of IPE exist but are often not institutionalized.
- Stage 4: Group play—IPE curriculum advances, with administrators recognizing the challenges and faculty champions receiving support to move IPE forward.
- Stage 5: Cultural transformation—IPE is being implemented well and is recognized by the wider university.11
Figure 2.2 Stages of IPE development.
This approach provides a road map for the stages of cultural transformation necessary to make IPE a sustained reality (for more on sustainability, see chapter 8). Despite the lack of clear evidence for an ideal IPE curriculum, the literature on teamwork and team science provides extensive support to pedagogical approaches. The reality remains that attitudes, behaviors, and skills that elicit successful IPCP do not require a clear end point of accomplishment or competence; rather, they require educators to prepare students for an ambiguous and unclear journey.13 This chapter provides a foundation to prepare learners (e.g., students, residents, fellows, clinicians, faculty) to gain the attitudes, behaviors, and skills to negotiate the contemporary health care landscape that is keenly focused on population health and societal needs.
Health care is a team sport
By Jordan Hamson-Utley
Health care is a team sport. Just as sport requires athleticism and sport-specific skills operating in synergy toward a goal, health care teams require captains, diverse skill sets, and coordination to improve a patient's health. In basketball, could a team of only point guards beat a championship team? This might be the health care equivalent of a team of only PTs providing care for a patient after a stroke, for example. Additionally, IPCP is essential for health care teams to achieve patient care goals. Each position on a team requires a unique set of skills; without a point guard, a basketball team would lack leadership, ball vision, communication, and a 3-point scoring threat. Similarly, without a case lead, a care team would lack leadership, planning, communication, and an opportunity to win by providing the best patient care possible.
Graduating team-ready health care professionals requires seasoned educators, those who are experts in best practices not only in the classroom but also in IPE facilitation. As a result of limited experience in IPE facilitation, many educators are slowing the adoption of IPE1 and potentially limiting the capacity of graduates to be ready to practice in a contemporary workplace. Literature to date is limited (but growing) in the area of faculty development for IPE, and existing research is not adequate to consider any method a best practice.2 However, promising findings across existing methodologies indicate the value of modeling IPE knowledge, skills, and attitudes (KSAs); group work; reflection; and appreciation of diversity.1
Educator development is a critical component in the effective delivery of IPE. For an interprofessional team to achieve its purpose, it must capitalize on the diverse knowledge and skills of the team. Delivering educator training in a collaborative framework affords exposure to teammates that promotes learning about each other, from each other, and with each other to devise strategies and solve problems related to classroom delivery or team-based patient care. The literature has established that continuing education that isolates health care professions prevents clinicians from developing collaborative capacities that meet the challenges of today's workplace.3,4 Programs that deliver learning using a teaming approach are best positioned to benefit from the role models and networks that are built into this approach. Faculty and clinicians who are expected to engage in IPE and the team-based learning of future clinicians must be supported with the knowledge and skills necessary to design and facilitate IPE.5
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