The new model for health care delivery calls for effective physician-nurse teamwork. But teamwork is a challenge for many health care organizations, as interprofessional conflict between nurses and physicians is widespread and well-documented.
Team training is often not sufficient to overcome obstacles such as nurses' heightened expectations of relationship power, physicians' feelings of loss of autonomy, role ambiguity in the new team setting, and professional cultural differences between doctors and nurses. Organizations must incorporate, measure and reward team-oriented behaviors to sustain them.
The following case study describes a hospital team with a long history of conflict. Through multilevel coaching and conflict behavior assessment, implemented over five months, team members were able to increase their self-awareness, become more open to others' opinions and practice positive behaviors.
A Team at an Impasse
In an East Coast hospital, blame and negativity between the doctors and nurses of a subspecialty group permeated the culture of their inpatient units. The doctors and nurses, who had been in their roles for a significant time, had undergone hospitalwide communications training, but it was not evident in their behaviors. Another previous intervention had not been successful.
Everyone had given up hope that the other professionals would change their behaviors. Floor nurses made periodic complaints about the doctors, and the doctors were frustrated with a perceived lack of respect from nurses and administrators. A common complaint was a seeming use or abuse of the "power gradient." Although everyone focused on clinical care excellence, hospital executives were concerned that the situation could lead to an adverse patient outcome.
The chief medical officer and chief nursing officer launched and led a working group comprising the unit nurse managers, the vice president for patient services and the physicians. It took several meetings to agree on the group's mission and values, but the group could not agree on patient unit process improvements. At that point, the hospital hired an external organizational consultant to analyze the interpersonal and group dynamics and help the group to implement improvements.
Team Dynamics Survey and Results
The consultant met individually with each member of the working group to confidentially administer a questionnaire about team strengths and weaknesses. She also began developing one-on-one relationships based on trust and open communication.
The consultant presented the findings and recommendations to the working group in an objective, balanced manner. In prefacing the presentation, the consultant emphasized that both nurses and physicians had valid concerns, and that everyone was part of both the problem and the solution. The findings were noted in two categories:
- interpersonal and group dynamics problems, the most important of which were poor communications, lack of trust, high level of unresolved conflict and lack of effective teamwork;
- conflict "flashpoint" issues raised by multiple respondents to the questionnaire, such as lack of interdisciplinary rounds, disconnects in formal communication channels, and absence of coordination before undertaking discussions with patients and families.
The consultant proposed incorporating self-assessments, coaching individuals and professional subgroups, and whole-group facilitation.
Coaching and Self-assessment
Each working group member took the Conflict Dynamics Profile and had a coaching session to discuss results. The CDP is an evidence-based, statistically valid and reliable self-assessment that measures preferences for conflict-related behaviors. It helps individuals become more aware of their own conflict behaviors.
The confidential coaching sessions gave each group member a safe space to see his or her strengths and weaknesses. Discussions included reviewing actual conflict experiences and encouraging participants to stretch their insights to understand others' viewpoints. The accompanying CDP Development Guide provided specific suggestions for behavior changes. By the end of each coaching session, each person committed to bringing one strength to the working group to improve group dynamics, and to share one weakness.
In separate meetings with each professional subgroup, the consultant acknowledged the frustrations of the physicians and unit nursing leaders. She also sought their views on problems and causes and how each distinct subgroup could contribute to solutions. She facilitated discussions, provided feedback and helped them to find common ground.
Facilitating Whole-Group Dynamics
In a working group meeting, everyone shared his or her conflict-related strength and weakness. Members discussed underlying assumptions about their roles and those of others as well as perspectives that cause conflict. This created mutual understanding, more openness and hope for better relationships. In that meeting, several participants began exhibiting conflict-improvement behaviors learned in the individual coaching sessions.
The consultant introduced two other best practices for running effective meetings in the working group: Robert's Rules of Order and ground rules for constructive team member behaviors. Copies of both were distributed to team members and were made available at every meeting. Robert's Rules of Order helped team members to structure their conversations, define problems and discuss solutions. The ground rules included specific communication practices that operationalized ways to understand and appreciate other parties' viewpoints, look for common ground, disagree respectfully and hold themselves accountable in following the norms.
Along with customary team facilitation functions, the consultant reminded members to adopt these norms during working group meetings. The hospital's vice president for patient services strongly advocated and modeled the desired behaviors. Over the course of several meetings, the members also began to exhibit the behaviors, which changed the group dynamic and resulted in better listening, constructive airing of concerns and collaborative problem-solving.
Outcomes and Success Factors
The team's progress created the positive momentum for the team to achieve its first major breakthrough: It was able to agree upon and successfully implement a complex workflow process for interdisciplinary bedside rounds. This process incorporated a patient-centered, evidence-based checklist. The hospital president received unsolicited positive feedback from other nurses and physicians, who had observed the lessened tension and better cooperation in the clinical units.
The major challenges that this physician-nurse team faced are common, so the success factors can be applied to an interdisciplinary team in a broad range of hospital and health care settings.
Key challenges were:
- resistance to change, as well as overcoming boundaries of nurse and physician subcultures to develop collaborative mindsets and work toward common goals;
- lack of trust within the group.
Key success factors were:
- active involvement from the chief medical officer and chief nursing officer, in particular using their positions to reinforce the need for change, regularly communicating the overarching goals of patient safety and quality improvement, and monitoring progress;
- an external organization consultant who consistently demonstrated objectivity, fairness and confidentiality, so that all parties could build trust;
- use of the Conflict Dynamics Profile self-assessment to build each team member's self-awareness and knowledge of conflict-related behaviors;
- coaching on the individual, professional subgroup (doctors and nurses) and whole-group levels, which provided team members consistency and a safe space to practice new behaviors and receive helpful feedback;
- active facilitation of group dynamics, including Robert's Rules of Order and ground rules for constructive communications and collaboration;
- choice of a high-impact project for the team to design and implement with clear outcomes, roles, accountabilities and performance expectations;
- an administrative leader (in this case, the vice president for patient services) who was open to change, had strong leadership skills and could carry the team forward once initial breakthroughs were made.
Better Communication, More Patient Satisfaction
A successful intervention combining multilevel coaching and conflict behavior assessment, implemented over five months, increased team members' self-awareness, openness to others' opinions and practice of positive behaviors.
The team members were able to achieve a major breakthrough in implementing a complex workflow process for interdisciplinary bedside rounds. Their agreed-upon goals included more efficient clinical decision-making, better patient- and family-focused communications, and more employee satisfaction. Hospital executives initially concerned about poor teamwork could now report positive feedback from nurses and physicians alike.
Barbara Eiser, M.A., M.C.P., P.C.C., is the president of Leading Impact Inc., a firm in Bryn Mawr, Pa., focusing on executive coaching, team transformation and leadership training.