From a patient safety point of view, well-functioning teams offer great promise to deliver superior care. Poorly functioning teams, and poorly communicating teams in particular, increase safety risks for patients. In order to deliver safe medical care, teams must know and understand what is going on around them. Effective collaborative care is rooted in both psychological safety and team situational awareness.
Team situational awareness refers to the collective understanding of unfolding situations. It is critical for effective decision making and guiding the coordination of care. Individual team members scan the environment for new information and new developments and share these with the team. The sharing of these multiple perspectives creates a shared mental model to address the specific patient needs.
The foundation for this effective sharing of information is a culture of psychological safety, which empowers core team behaviours that create and maintain situational awareness. Shared situational awareness is difficult to achieve in a culture of hierarchy or fear.
The Canadian Interprofessional Health Collaborative, a national hub fostering collaborative healthcare practice, has identified six core competencies for effective teams:
- Role clarification
- Collaborative leadership
- Team functioning
- Conflict resolution skills
Effective team communication can help improve outcomes for patients.
Effective team communication includes such practices as:
- using structured communication tools
- employing strategies to improve handovers
- engaging in huddles
- using structured briefings and debriefings (such as the surgical safety checklist)
- thinking out loud
- empowering others to speak up
Communication within teams is challenging in the following situations:
- team members do not actively listen to each other, the patient, or the family
- team members have different communication styles or do not share a common vocabulary and misunderstand each other
- there is uncertainty or confusion about the roles and responsibilities of team members
- there is an assumption that a consultant will understand what is wanted, without an explicit question or explanation of the clinical concerns
- hierarchies or behaviours interfere with conveying important information about the patient's medical condition and status, or issues in care
Collaborative teams employ the skills of the most appropriate healthcare provider for the care required. When care is shared with other providers, speaking up and listening up are ways that team members can enhance patient safety. A team culture that leverages individual situational awareness and enables cross-monitoring principles can promote continuous learning and contribute to safe care.
- patients are considered integral partners on the team
- information is shared with patients and families (with the patient’s permission) in a manner that is always respectful, patient-centred, and encourages active participation in decision-making
- patients are listened to, so team members fully understand their needs for care
- patients are encouraged to speak up
Dealing with conflict
Conflict is inevitable in our professional lives. Conflict can arise with patients, families, physician colleagues, other healthcare professionals, administrators, and others. Well-managed conflict can lead to the discovery of broader perspectives or the identification of constructive changes. It can also provide opportunities to learn and to improve communication, processes, and interactions. By contrast, mismanaged conflict can undermine the creation or maintenance of a collaborative care team and a psychologically safe environment, and can adversely affect the safety of medical care.
Active listening, agreeing, acknowledging, and apologizing are communication skills that can de-escalate conflict.
Professionalism demands that team members deal with each other with respect and courtesy at all times. Disparaging remarks about team members should not be made nor should a team member be belittled or embarrassed.
The composition of collaborative care teams depends on patient needs, available resources and the environment in which care is provided. Teams often comprise a wide range of professionals, both regulated and unregulated, including trainees, physician assistants, nurses, pharmacists, and physiotherapists. Teams may also include local community health representatives, health and social service providers, family service workers, aestheticians, mental health workers, grief counsellors, clergy, and traditional healers, elders, and band counsellors.
Clarifying roles and responsibilities
Scope of practice is the range of healthcare tasks, decisions, or activities that a regulated healthcare professional is allowed to perform by law and the relevant provincial/territorial licensing authority.
A scope of practice is a general boundary and does not necessarily imply that an individual provider has the knowledge, skills, or experience to safely perform all allowed activities within that boundary. Physicians and other healthcare providers should only practice in areas authorized by their scope of practice and in which they are educated, skilled and experienced. There are also institutional directives that may limit the activities of certain types of providers in their local context, even though these providers may have a potential larger scope of practice in other environments. These decisions are dependent upon each institution.
Healthcare professionals should understand and respect their own scope of practice and those of other team members. Scopes of practice can vary according to province or territory as well as from institution to institution and are continually evolving over time.
- Tasks that fall within a physician’s scope of practice may be delegated as appropriate to both regulated and unregulated team members, provided the physician is satisfied that the team member has the appropriate training and supervision.
- Hospitals or licensing authorities may impose additional requirements for non-physicians to carry out certain restricted activities so physicians should be aware of any relevant policies that place further limits on delegation.
- Generally, tasks do not need to be delegated or supervised by a physician when that task is part of the scope of practice of another team member who will be completing the task. If a physician does delegate or supervise where it is not required, they will assume responsibility for the delegation and for appropriately supervising the delegated task.
The central concern in framing collaborative care should always be patients’ best interests, with consideration also given to what works best in the team’s particular circumstances. When each member understands their own role and the roles of the other team members, they can be clear on their own accountability and share care appropriately.
- Where scopes of practice within a team overlap, the roles and responsibilities of each member should be clear and well-documented. Developing sound policies and procedures to guide collaborative care is an important step in establishing consistency between providers within teams.
- Each individual's role is defined by that person's training and competency as well as by institutional policy and the needs of the patient population served. All healthcare providers are generally expected to follow sound institutional policies, regardless of individual preferences or beliefs.
- Trainees are an integral part of many teams and should contribute to care and be supervised at a level appropriate to their level of training. See also the “Delegation and supervision of trainees” section.
Highly reliable teams:
- define and understand the roles and responsibilities of individual members of the team
- know when tasks need to be delegated and/or supervised depending on the scopes of practice of individual team members and their training, experience and skills
- maintain appropriate supervision of delegated tasks
- understand how decision-making occurs and know how to raise concerns effectively and professionally
- distribute tasks appropriately
- understand what knowledge and skills need to be developed
- provide new team members with a proper orientation
- foster psychological safety
- incorporate learning and continuous improvement as part of their work
In Québec, health professionals are only permitted to perform acts authorized by their relevant governing legislation and in accordance with specified requirements, if any. Accordingly, physicians can only request that another health professional perform a reserved act if the legislation governing these other health professionals authorize them to perform that act.
Considerations discussed in this publication also apply in Québec where a Regulation allows medical students and residents to carry out reserved acts assigned to them under the supervision of a physician.
The most responsible physician (or provider) (MRP) is typically the leader of collaborative care for their patient in institutional settings. The MRP is the provider who has overall responsibility for directing, coordinating care, and managing a patient at a specific point in time. It is important to avoid ambiguity and confusion, especially when scopes of practice within a team overlap. There should be open communication and clear documentation of the role of team members, especially if the MRP changes.
Good team leaders:
- serve as role models for teamwork, provide motivation, and foster cohesion within the team
- structure and regulate team processes and effective information sharing
- consult and listen
- prepare for the unexpected
- are aware of current situations (maintain and promote "situational awareness")
- foster learning from near-misses and patient safety incidents
- are fair in management of patient safety incidents
- incorporate continuous learning in everyday activities
In well-functioning healthcare teams, the desire for learning and improvement is visible. Leaders can build such teams by empowering providers to do what is necessary to promote safe medical care without fear of unfair reprisals. Leaders can create a just culture in an environment characterized by appropriate accountability, and thereby set the stage for highly reliable care delivery.
A robust policy and procedure framework helps reduce ambiguity and confusion and supports collaborative care. The framework should ensure the team has sufficient resources to achieve the desired health outcomes and that there is a quality improvement mechanism to monitor the team’s functioning in the context of processes and health outcomes.
Policies governing scope of practice and collaborative care should be reviewed regularly to consider and incorporate best practices, evolving institutional realities, as well as reviews of near-misses and patient safety incidents (accidents in Québec). To decrease clinical risk for patients and medico-legal risk for individual providers, teams can:
- clearly define the roles and responsibilities of each team member, based on their scopes of practice and also the individual's knowledge, skill, and ability
- establish how health care decisions will be made
- establish a continuous quality improvement process
- create processes that install the patient as an integral member of the team
- establish a process to manage patient expectations and respond to patient concerns