Chapter 33. Professional Communication and Team 

Collaboration 

Michelle O’Daniel, Alan H. Rosenstein 

Background 

In today’s health care system, delivery processes involve numerous interfaces and patient 

handoffs among multiple health care practitioners with varying levels of educational and 

occupational training. During the course of a 4-day hospital stay, a patient may interact with 50 

different employees, including physicians, nurses, technicians, and others. Effective clinical 

practice thus involves many instances where critical information must be accurately 

communicated. Team collaboration is essential. When health care professionals are not 

communicating effectively, patient safety is at risk for several reasons: lack of critical 

information, misinterpretation of information, unclear orders over the telephone, and 

overlooked changes in status.1

 

Lack of communication creates situations where medical errors can occur. These errors 

have the potential to cause severe injury or unexpected patient death. Medical errors, 

especially those caused by a failure to communicate, are a pervasive problem in today’s health 

care organizations. According to the Joint Commission (formerly the Joint Commission on 

Accreditation of Healthcare Organizations, JCHAO), if medical errors appeared on the National 

Center for Health Statistic’s list of the top 10 causes of death in the United States, they would 

rank number 5—ahead of accidents, diabetes, and Alzheimer’s disease, as well as AIDS, breast 

cancer, and gunshot wounds.1

 The 1999 Institute of Medicine (IOM) report, To Err Is Human: 

Building a Safer Health System, revealed that between 44,000 and 98,000 people die every year 

in U.S. hospitals because of medical errors.2 Even more disturbing, communication failures are 

the leading root cause of the sentinel events reported to the Joint Commission from 1995 to 

2004. More specifically, the Joint Commission cites communication failures as the leading root 

cause for medication errors, delays in treatment, and wrong-site surgeries, as well as the second 

most frequently cited root cause for operative and postoperative events and fatal falls.1 

Traditional medical education emphasizes the importance of error-free practice, utilizing 

intense peer pressure to achieve perfection during both diagnosis and treatment. Errors are 

therefore perceived normatively as an expression of failure. This atmosphere creates an 

environment that precludes the fair, open discussion of mistakes required if organizational 

learning is to take place. In the early 1990s, Donald Berwick wrote about patients needing an 

open communication system instead of experiencing adverse events stemming from 

communication failures.3 More than a decade later, this concept still has profound 

implications on our method of health care delivery. As such, this chapter will review the 

literature on the important role of communication and team collaboration in helping to 

reduce medical errors and increase patient safety. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

Research Evidence 

What Are Communication and Team Collaboration? 

Webster’s Dictionary defines communication as “the imparting or interchange of thoughts, 

opinions, or information by speech, writing, or signs.” It is important to consider that 

communication is not just verbal in form. One study states that 93 percent of communication is 

more affected by body language, attitude, and tone, leaving only 7 percent of the meaning and 

intent based on the actual words said.4

 Whereas the spoken words contain the crucial content, 

their meaning can be influenced by the style of delivery, which includes the way speakers stand, 

speak, and look at a person.1 However, critical information is often transmitted via handwritten 

notes, e-mails, or text messages, which can lead to serious consequences if there is 

miscommunication. 

Collaboration in health care is defined as health care professionals assuming complementary 

roles and cooperatively working together, sharing responsibility for problem-solving and making 

decisions to formulate and carry out plans for patient care.5, 6 Collaboration between physicians, 

nurses, and other health care professionals increases team members’ awareness of each others’ 

type of knowledge and skills, leading to continued improvement in decisionmaking.7 

Effective teams are characterized by trust, respect, and collaboration. Deming8 is one of 

the greatest proponents of teamwork. Teamwork, he believes, is endemic to a system in which all 

employees are working for the good of a goal, who have a common aim, and who work together 

to achieve that aim. When considering a teamwork model in health care, an interdisciplinary 

approach should be applied. Unlike a multidisciplinary approach, in which each team member is 

responsible only for the activities related to his or her own discipline and formulates separate 

goals for the patient, an interdisciplinary approach coalesces a joint effort on behalf of the patient 

with a common goal from all disciplines involved in the care plan. The pooling of specialized 

services leads to integrated interventions. The plan of care takes into account the multiple 

assessments and treatment regimens, and it packages these services to create an individualized 

care program that best addresses the needs of the patient. The patient finds that communication is 

easier with the cohesive team, rather than with numerous professionals who do not know what 

others are doing to mange the patient.9

 Table 1 is a compilation of some of the components found 

in the literature of a successful teamwork model.10–14 

It is important to point out that fostering a team collaboration environment may have hurdles 

to overcome: additional time; perceived loss of autonomy; lack of confidence or trust in 

decisions of others; clashing perceptions; territorialism; and lack of awareness of one provider of 

the education, knowledge, and skills held by colleagues from other disciplines and professions.15

However, most of these hurdles can be overcome with an open attitude and feelings of mutual 

respect and trust. A study determined that improved teamwork and communication are described 

by health care workers as among the most important factors in improving clinical effectiveness 

and job satisfaction.16 

Table 1. Components of Successful Teamwork 

• Open communication 

• Nonpunitive environment 

• Clear direction 

• Clear and known roles and tasks for team members 

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Communication & Teamwork 

• Respectful atmosphere 

• Shared responsibility for team success 

• Appropriate balance of member participation for the task at hand 

• Acknowledgment and processing of conflict 

• Clear specifications regarding authority and accountability 

• Clear and known decisionmaking procedures 

• Regular and routine communication and information sharing 

• Enabling environment, including access to needed resources 

• Mechanism to evaluate outcomes and adjust accordingly 

Extensive review of the literature shows that communication, collaboration, and teamwork 

do not always occur in clinical settings. For example, a study by Sutcliff, Lewton, and 

Rosenthal17 reveals that social, relational, and organizational structures contribute to 

communication failures that have been implicated as a large contributor to adverse clinical 

events and outcomes. Another study shows that the priorities of patient care differed between 

members of the health care team, and that verbal communication between team members was 

inconsistent.16 Other evidence shows that more than one-fifth of patients hospitalized in the 

United States reported hospital system problems, including staff providing conflicting 

information and staff not knowing which physician is in charge of their care.18 Over the past 

several years, we have been conducting original research on the impact of physician and nurse 

disruptive behaviors (defined as any inappropriate behavior, confrontation, or conflict, ranging 

from verbal abuse to physical or sexual harassment) and its effect on staff relationships, staff 

satisfaction and turnover, and patient outcomes of care, including adverse events, medical errors, 

compromises in patient safety, poor quality care, and links to preventable patient mortality. 

Many of these unwanted effects can be traced back to poor communication and collaboration, 

and ineffective teamwork.19–22

Unfortunately, many health care workers are used to poor communication and teamwork, as 

a result of a culture of low expectations that has developed in many health care settings. This 

culture, in which health care workers have come to expect faulty and incomplete exchange of 

information, leads to errors because even conscientious professionals tend to ignore potential red 

flags and clinical discrepancies. They view these warning signals as indicators of routine 

repetitions of poor communication rather than unusual, worrisome indicators.23

Although poor communication can lead to tragic consequences, a review of the literature also 

shows that effective communication can lead to the following positive outcomes: improved 

information flow, more effective interventions, improved safety, enhanced employee morale, 

increased patient and family satisfaction, and decreased lengths of stay.1, 24–26 Fuss and 

colleagues27 and Gittell and others28 show that implementing systems to facilitate team 

communication can substantially improve quality. 

Effective communication among staff encourages effective teamwork and promotes 

continuity and clarity within the patient care team. At its best, good communication encourages 

collaboration, fosters teamwork, and helps prevent errors. 

Barriers to Effective Communication 

Health professionals tend to work autonomously, even though they may speak of being part 

of a team.29 Efforts to improve health care safety and quality are often jeopardized by the 

communication and collaboration barriers that exist between clinical staff. Although every 

organization is unique, the barriers to effective communication that organizations face have 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

some common themes. Table 2 indicates some common barriers to interprofessional 

collaboration that we have learned from our research and focus groups with hospitals across the 

country. 

Table 2. Common Barriers to Interprofessional Communication and Collaboration 

• Personal values and expectations 

• Personality differences 

• Hierarchy 

• Disruptive behavior 

• Culture and ethnicity 

• Generational differences 

• Gender 

• Historical interprofessional and intraprofessional rivalries 

• Differences in language and jargon 

• Differences in schedules and professional routines 

• Varying levels of preparation, qualifications, and status 

• Differences in requirements, regulations, and norms of professional education 

• Fears of diluted professional identity 

• Differences in accountability, payment, and rewards 

• Concerns regarding clinical responsibility 

• Complexity of care 

• Emphasis on rapid decisionmaking

The barriers indicated in Table 2 can occur within disciplines, most notably between 

physicians and residents, surgeons and anesthesiologists, and nurses and nurse managers.30, 31

However, most often the barriers manifest between nurses and physicians. Even though doctors 

and nurses interact numerous times a day, they often have different perceptions of their roles and 

responsibilities as to patient needs, and thus different goals for patient care. One barrier 

compounding this issue is that because the United States is one of the most ethnically and 

culturally diverse countries in the world, many clinicians come from a variety of cultural 

backgrounds. In all interactions, cultural differences can exacerbate communication 

problems.1 For example, in some cultures, individuals refrain from being assertive or 

challenging opinions openly. As a result, it is very difficult for nurses from such cultures to 

speak up if they see something wrong. In cultures such as these, nurses may communicate 

their concern in very indirect ways. Culture barriers can also hinder nonverbal 

communication. For example, some cultures ascribe specific meaning to eye contact, 

certain facial expressions, touch, tone of voice, and nods of the head. 

Issues around gender differences in communication styles, values, and expectations are 

common in all workplace situations. In the health care industry, where most physicians are male 

and most nurses are female, communication problems are further accentuated by gender 

differences.32 

A review of the organizational communication literature shows that a common barrier to 

effective communication and collaboration is hierarchies.33–37 Sutcliff and colleagues’ research17

concurs that communication failures in the medical setting arise from vertical hierarchical 

differences, concerns with upward influence, role conflict, and ambiguity and struggles with 

interpersonal power and conflict. Communication is likely to be distorted or withheld in 

situations where there are hierarchical differences between two communicators, particularly 

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Communication & Teamwork 

when one person is concerned about appearing incompetent, does not want to offend the other, or 

perceives that the other is not open to communication.

In health care environments characterized by a hierarchical culture, physicians are at the top 

of that hierarchy. Consequently, they may feel that the environment is collaborative and that 

communication is open while nurses and other direct care staff perceive communication 

problems. Hierarchy differences can come into play and diminish the collaborative interactions 

necessary to ensure that the proper treatments are delivered appropriately. When hierarchy 

differences exist, people on the lower end of the hierarchy tend to be uncomfortable speaking up 

about problems or concerns. Intimidating behavior by individuals at the top of a hierarchy can 

hinder communication and give the impression that the individual is unapproachable.1, 38 

Staff who witness poor performance in their peers may be hesitant to speak up because 

of fear of retaliation or the impression that speaking up will not do any good. Relationships 

between the individuals providing patient care can have a powerful influence on how and even if 

important information is communicated.Research has shown that delays in patient care and 

recurring problems from unresolved disputes are often the by-product of physician-nurse 

disagreement.39 Our research has identified a common trend in which nurses are either reluctant 

or refuse to call physicians, even in the face of a deteriorating status in patient care. Reasons for 

this include intimidation, fear of getting into a confrontational or antagonistic discussion, lack of 

confidentiality, fear of retaliation, and the fact that nothing ever seems to change. Many of these 

issues have to deal more with personality and communication style.40 The major concern about 

disruptive behaviors is how frequently they occur and the potential negative impact they can 

have on patient care. Our research has shown that 17 percent of respondents to our survey 

research in 2004-2006 knew of a specific adverse event that occurred as a result of disruptive 

behavior. A quote from one of the respondents illustrates this point: “Poor communication postop because of disruptive reputation of physician resulted in delayed treatment, aspiration, and 

eventual demise.”19

Leaders in both medicine and nursing have issued ongoing initiatives for the development of 

a cooperative rather than a competitive agenda to benefit patient care.5, 39, 41, 42 A powerful 

incentive for greater teamwork among professionals is created by directing attention to the areas 

where changes are likely to result in measurable improvements for the patients they serve 

together, rather than concentrating on what, on the surface, seem to be irreconcilable professional 

differences. The fact that most health professionals have at least one characteristic in common, a 

personal desire to learn, and that they have at least one shared value, to meet the needs of their 

patients or clients, is a good place to start. 

Practice Implications

Known Benefits of Communication and Team Collaboration 

A large body of literature shows that because of the complexity of medical care, coupled with 

the inherent limitations of human performance, it is critically important that clinicians have 

standardized communication tools and create an environment in which individuals can speak up 

and express concerns. This literature concurs that when a team needs to communicate complex 

information in a short period of time, it is helpful to use structured communication 

techniques to ensure accuracy. Structured communication techniques can serve the same 

purpose that clinical practice guidelines do in assisting practitioners to make decisions and 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

take action. Research from aviation and wilderness firefighting is useful in health care because 

they all involve settings where there is a huge variability in circumstances, the need to adapt 

processes quickly, a quickly changing knowledge base, and highly trained professionals who 

must use expert judgment in dynamic settings. Research shows that in these disciplines, the 

adoption of standardized tools and behaviors is a very effective strategy in enhancing teamwork 

and reducing risks.1, 17, 43–54, 60, 61 

Crew Resource Management (Aviation). Experts in aviation have developed safety 

training focused on effective team management, known as Crew Resource Management (CRM). 

Improvements in the safety record of commercial aviation may be due, in part, to this training.

Realizing that 70 percent of commercial flight accidents stemmed from communication failures 

among crew members, CRM sought to standardize communication and teamwork. The concept 

originated in 1979, in response to a NASA workshop that examined the role that human error 

plays in air crashes. CRM emphasizes the role of human factors in high-stress, high-risk 

environments. John K. Lauber, a psychologist member of the National Transportation Safety 

Board, deemed CRM as “using all available sources—information, equipment, and people—to 

achieve safe and efficient flight operations.”44, 45 CRM encompasses team training as well as 

simulation, interactive group debriefings, and measurement and improvement of aircrew 

performance. This represents a major change in training, which had previously dealt with only 

the technical aspects of flying. It considers human performance limiters (such as fatigue and 

stress) and the nature of human error, and it defines behaviors that are countermeasures to error, 

such as leadership, briefings, monitoring and cross-checking, decisionmaking, and review and 

modification of plans. From a practical standpoint, CRM programs typically include educating 

crews about the limitations of human performance. Trainees develop an understanding of 

cognitive errors and how stressors (such as fatigue, emergencies, and work overload) contribute 

to the occurrence of errors. Operational concepts stressed include inquiry, seeking relevant 

operational information, advocacy, communicating proposed actions, conflict resolution, and 

decisionmaking. CRM is now required for flight crews worldwide. 

The development and implementation of CRM in aviation over the last 25 years offers 

valuable lessons for medical care. Sexton and colleagues51 compared flight crews with operating 

room personnel on several measures, including attitudes toward teamwork. This landmark study 

included more than 30,000 cockpit crew members (captains, first officers, and second officers) 

and 1,033 operating room personnel (attending surgeons, attending anesthesiologists, surgical 

residents, anesthesia residents, surgical nurses, and anesthesia nurses). Questionnaires were sent 

to crew members of major airlines around the world (over a 15-year period). The operating room 

participants were mailed an analogous questionnaire, administered over a period of 3 years at 12 

teaching and nonteaching hospitals in the United States, Italy, Germany, Switzerland, and Israel. 

The Sexton study and other analyses suggest that safety-related behaviors that have been 

applied and studied extensively in the aviation industry may also be relevant in health care. 

Study results show successful CRM applications in several dynamic decisionmaking health care 

environments: the operating room, labor and delivery, and the emergency room.26, 31, 55, 56 As with 

aviation, the medical application of CRM has required tailoring of training approaches to mirror 

the areas in which human factors contribute to mishaps. In anesthesiology, 65–70 percent of 

safety problems (accidents or incidents) have been attributed at least in part to human error. In 

response, several anesthesiologists from the Veterans Affairs Palo Alto Health Care System and 

Stanford University developed Anesthesia Crisis Resource Management (ACRM), modeled 

on CRM.55 Kaiser Permanente, a nonprofit American health care system providing care for 8.3 

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Communication & Teamwork 

million patients, has also adopted CRM with successful results.54 In response to the occurrence 

of a sentinel event—a medical error with serious consequences—Eglin U.S. Air Force (USAF) 

Regional Hospital developed and implemented a patient safety program called Medical Team 

Management (MTM) that was modeled on the aviation industry’s CRM program and focused on 

communication, teamwork, and reporting to determine the impact of a patient safety program on 

patterns of medical error reporting.57 This study was a retrospective review of 1,102 incident 

reports filed at Eglin USAF Regional Hospital in Florida between 1997 and 2001. Collected data 

from the comparison periods (1998 and 2001) were statistically analyzed using the chi-square 

test. This study indicates that, since the implementation of MTM, there has been a statistically 

significant increase in the number of reports filed at Eglin USAF Regional Hospital and a decline 

in the severity of incidents. These findings suggest that since the implementation of MTM, there 

have been changes in the patterns of error reporting, and with training, staff are able to prevent 

more serious incidents. Table 3 highlights the application of a CRM model to medicine. 

Table 3. Application of a CRM Model to Medicine 

• Design of systems to absorb errors through redundancy, standardization, and checklists 

• Movement from placing blame to designing safe processes and procedures, i.e., applying a 

systems approach 

• Assurance of full immunity while implementing a nonpunitive approach 

• Debriefing of all events, including near misses, that have learning potential. Focus on the 

severity of the potential risk rather than on the severity of the event's final outcome is more 

conducive to establishing effective prevention programs. 

• Institutionalization of a permanent program for risk identification, analysis, and dissemination of 

the lessons learned throughout the professional community 

SBAR. Doctors and nurses often have different communication styles in part due to training. 

Nurses are taught to be more descriptive of clinical situations, whereas physicians learn to be 

very concise. Standardized communication tools are very effective in bridging this difference in 

communication styles. 

Michael Leonard, physician coordinator of clinical informatics at Kaiser Permanente, along 

with colleagues, developed a technique called SBAR (Situation-Background-AssessmentRecommendation). This technique has been implemented widely at health systems such as 

Kaiser Permanente.1, 17, 58 Many other hospitals have embraced the SBAR communication tool or 

a similar tool created by the Studer Group (see Table 4).59 For example, the Queen’s Medical 

Center in Honolulu has incorporated the SBAR tool as a key component of its patient safety 

program. The SBAR technique provides a framework for communication between members of 

the health care team about a patient’s condition. SBAR is an easy-to-remember tool used to 

create mechanisms useful for framing any conversation, especially critical ones, requiring a 

clinician’s immediate attention and action. It allows for an easy and focused way to set 

expectations between members of the team for what will be communicated and how, which is 

essential for information transfer and cohesive teamwork. Not only is there familiarity in how 

people communicate, but the SBAR structure helps develop desired critical-thinking skills. The 

person initiating the communication knows that before they pick up the telephone, they need to 

provide an assessment of the problem and what they think an appropriate solution is. Their 

conclusion may not ultimately be the answer, but there is clearly value in defining the situation.

Table 5, Guidelines for Communicating with Physicians Using the SBAR Process explains how 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

to carry out the SBAR technique in detail. The guidelines use the physician team member as the 

example; however, they can be adapted for use with all other health professionals. 

Table 4. Studer Group Communication Guidelines for Nurses 

• Have I seen and assessed this patient myself before I call? 

• Are there standing orders? 

• Do I have at hand 

o The chart? 

o List of current meds, IV fluids, and labs? 

o Most recent vital signs? 

o If reporting lab work, date and time this test was done and results of previous tests for 

comparisons? 

o Code status? 

• Have I read the most recent MD progress notes and notes from the nurse who worked the shift 

ahead of me? 

• Have I discussed this call with my charge nurse? 

• When ready to call, 

Remember to identify self, unit, patient, room number. 

o Know the admitting diagnosis and date of admission. 

o Briefly state the problem, what it is, when it happened or started, and how severe it is. 

• What do I expect to happen as a result of this call? 

• Document whom you spoke to, time of call, and summary of conversation. 

• Engage and treat physician with respect. 

[Source: Studer Group. Patient Safety Toolkit – Practical tactics that improve both patient safety and patient perceptions of care. 

Gulf Breeze, FL: Studer Group., 2007.] 

Table 5. SBAR (Situation, Background, Assessment, Recommendation) 

3⁄4 SBAR – a technique for communicating critical information that requires immediate attention and 

action concerning a patient’s condition 

3⁄4 Situation – What is going on with the patient? 

“I am calling about Mrs. Joseph in room 251. Chief complaint is shortness of breath of new 

onset.” 

3⁄4 Background – What is the clinical background or context? 

“Patient is a 62-year-old female post-op day one from abdominal surgery. No prior history of 

cardiac or lung disease.” 

3⁄4 Assessment – What do I think the problem is? 

“Breath sounds are decreased on the right side with acknowledgment of pain. Would like to rule 

out pneumothorax.” 

3⁄4 Recommendation – What would I do to correct it? 

“I feel strongly the patient should be assessed now. Are you available to come in?”

[Note: Kaiser Permanente, SBAR (Situation, Background, Assessment, Recommendation) tool, 2002. Source for version in this 

table: Institute for Healthcare Improvement. Guidelines for communicating with physicians using the SBAR process. 

http://www.ihi.org/IHI/Topics/PatientSafety /SafetyGeneral/ Tools/SBARTechniq ueforCommunicationASituationalBriefing 

Model.htm. Accessed Nov. 18, 2004.] 

STICC (Situation Task Intent Concern Calibrate) is another type of structured briefing 

protocol used by the U.S. Forest Service to give direction to firefighters.1, 17, 60, 61 The 

following five steps are involved: 

• Situation: Here's what I think we face. 

• Task: Here's what I think we should do. 

• Intent: Here's why. 

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Communication & Teamwork 

• Concern: Here's what we should keep our eye on. 

• Calibrate: Talk to me. Tell me if you don't understand, can't do it, or see 

something I do not. 

Establishing Culture To Support Communication and 

Team Collaboration 

The literature reviewed shows that effective teams are characterized by common 

purpose and intent, trust, respect, and collaboration. Team members value familiarity over 

formality and watch out for each other to make sure mistakes are not made. Health care 

teams that do not trust, respect, and collaborate with one another are more likely to make a 

mistake that could negatively impact the safety of patients.

One of the first crucial steps is organizational commitment and willingness to address the 

situation. Commitment needs to come from the top down and bottom up, making a statement 

about the way the organization does business. The rallying point should be around behavioral 

standards and their relationship to patient safety. It’s ironic that ever since the publication of the 

original IOM report, To Err Is Human, organizations have spent the bulk of their time and efforts 

in improving patient systems rather than addressing the human factor issues highlighted in the 

original report.2

 Several recent reports have suggested that while we have made progress in the 

patient safety movement, we have a long way to go in meeting the IOM recommendations.62

Addressing defects in communication that affect collaboration, information exchange, 

appreciation of roles and responsibilities, and direct accountability for patient care are key 

components of any patient safety program. Clinical and administrative leaders must set the tone 

by establishing and adhering to behavioral standards that support agreed-upon code of conduct 

practices backed by a nonpunitive culture and zero-tolerance policy.

The next step in the process is recognition and self-awareness. Organizations must be able to 

assess the prevalence, context, and impact of behaviors to identify potential opportunities for 

improvement. Doing an internal assessment will help pinpoint the seriousness of the situation 

and provide clues to areas that need to be addressed. Assessment information can be gained from 

formal methods such as incident reports, survey tools, focus groups, department meetings, task 

forces or committees, direct observation, suggestion boxes, and hot lines. Informal methods such 

as casual meetings and gossip can also provide valuable surface information and should be 

evaluated more deeply as to the source, relevance, and significance of the events to determine 

next steps. In many organizations there are still remnants of reluctance to address the issue head 

on for fear of antagonizing a prominent surgeon or staff member. With growing concerns about 

workforce shortages, staff satisfaction and retention, hospital reputation, liability and patient 

safety, and the need for compliance to the latest Joint Commission proposed standards 

addressing disruptive behaviors, organizations can no longer afford to take a passive approach to 

the situation.63–66

Creating opportunities for different groups to just get together is a highly effective strategy 

for enhancing collaboration and communication. These group interactions can be either formal or 

informal. Encouraging open dialogue, collaborative rounds, implementing preop and postop 

team briefings, and creating interdisciplinary committees or task forces that discuss problem 

areas frequently provides an upfront solution that reduces the likelihood of disruptive events. 

When a disruptive event does occur, some organizations have implemented a time-out, code 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

white, or red light policy that addresses the issue in real time to prevent any further serious 

consequences.59

Developing and implementing a standard set of behavior policies and procedures is vital. 

These policies need to be consistent and universally applied. There should not be a separate 

policy for any one particular discipline or service. For the medical staff, the policies should 

become part of the medical staff bylaws with signed agreements to abide by these policies at the 

time of appointment and recredentialing. Included in the policies should be a standardized 

protocol outlining expected standards and the process for addressing disruptive behavior issues, 

recommendations, followup plans, and actions to be taken in the face of individual resistance or 

refusal to comply. Prior to implementation, make sure all employees are familiar with the 

existence, purpose, and intent of the policies and procedures. 

For the process to unfold, the organization needs to encourage its employees to report 

disruptive behaviors. The organization needs to address issues related to confidentiality, fear of 

retaliation, and the common feelings that there is a double standard and that nothing ever gets 

done. Reporting mechanisms should be made easy and must be supported by the presence of a 

nonpunitive environment. The ideal vehicle for reporting is to address the situation in real time, 

but concerns about position, appropriateness, receptiveness, fear, hostility, and retaliation are 

significant impediments.67 Appropriate vehicles for reporting may include reporting of the 

incident to a superior, filing an incident report, using a complaint or suggestion box, or reporting 

directly to a task force or interdisciplinary committee with assigned responsibilities for 

addressing these issues.59 Besides maintaining confidentiality and reducing risks of retaliation, 

one of the most crucial aspects of the reporting system is to give recognition and assurance that 

the complaints will be addressed and actions will be taken. Responses should be timely, 

appropriate, consistent, and provide necessary feedback and followup. 

Taking action though appropriate intervention strategies is next. On one level, generic 

educational programs can do a lot to spread the message and teach basic skills necessary to 

promote effective communication. Appropriate topics should include sessions on team dynamics, 

communication skills, phone etiquette, assertiveness training, diversity training, conflict 

management, stress management, and any other courses necessary to foster more effective team 

functioning and communication flow. Courses should be offered to all staff and employees at the 

organization: physicians, physicians in training, nurses, nursing students, and all other staff who 

have patient contact or play a role in the delivery of patient care. For individuals who have 

consistently exhibited disruptive behavior, education may need to be supported by more focused 

sessions and specific counseling. Another important strategy is to promote and assure 

competency training at all levels of the health care team. This is a key factor affecting trust and 

respect, which have such a strong influence on team collaboration. 

Focused team training programs have been of particular value. One of the newer approaches 

to improving team collaboration and patient safety is through the principles learned from the 

aviation industry. Fostering an environment of trust and respect, accountability, situational 

awareness, open communication, assertiveness, shared decisionmaking, feedback, and education, 

interdisciplinary CRM training has brought significant improvements to communication flow in 

the perioperative setting.52, 53

Having a clinical champion or early adopter who actively promotes the importance of 

appropriate behavior, communication, and team collaboration can be an extremely valuable 

asset. Champions can come from the executive ranks or through the voluntary interest and 

enthusiasm of other staff members. Co-champions may be even more effective. Some 

10 
Communication & Teamwork 

organizations have reported that having a nurse and physician (or other health care professional) 

go through a joint training program will help foster mutual cooperation and collaboration 

between the different disciplines.59 Followup and feedback bring closure to the process. It is 

important to let people know that their input is welcomed, followup actions will be taken, and 

appropriate feedback will be provided. 

Research Implications 

The existing literature adequately outlines structured communication techniques that will 

help minimize medical errors. However, more research is needed on how to effectively deal 

with miscommunication and barriers to communication in real-time crisis situations. Also, the 

existing literature lacks concrete research confirming a cause-and-effect relationship between 

human factors and clinical outcomes of care. 

Conclusions

Effective clinical practice must not focus only on technological system issues, but also on the 

human factor. As shown in this chapter, good communication encourages collaboration and helps 

prevent errors. It is important for health care organizations to assess possible setups for poor 

communication and be diligent about offering programs and outlets to help foster team 

collaboration. By addressing this issue, health care organizations have an opportunity to greatly 

enhance their clinical outcomes. 

Author Affiliations 

Michelle O’Daniel, M.H.A., M.S.G., director, member relations, VHA West Coast. E-mail: 

modaniel@vha.com. 

Alan H. Rosenstein, M.D., M.B.A., vice president and medical director, VHA West Coast. Email: arosenst@vha.com. 

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