Professionalism in nursing 2: working as part of a team (2023)

Teamwork in healthcare is about providing safe, effective and high-quality care. Nurses need to know how to work in a team, maintain professionalism and improve their teamworking skills

Introduction

All registered nurses have been part of a team at some point in their lives before they qualified, whether that was in a sporting team, a job, in education or as part of charitable work. When you are a nurse, teamwork is one of the key components of the role; not only does it link with the Nursing and Midwifery Council’s (2018) Code by prioritising people, practising effectively, preserving safety and promoting professionalism and trust, but it also creates a cohesive working environment, ensuring patients receive high-quality care that leads to improved patient outcomes.

Throughout this article – the second in a series on professionalism in nursing – task boxes guide reflections about teamwork. These are intended to help you gain an understanding of:

• How teams are constructed;
• The key skills that are needed to be part of a team;
• What makes a team successful.

Consider the task in Box 1 before continuing to read the rest of the article.

Nursing as a role is multifaceted, so it is no surprise that the teams of which nurses can be part are equally varied. Kalisch et al (2009) suggested that a nursing team is “two or more staff who work together to provide care and administrative tasks for a group of patients”. It could be reasoned that this is an over-simplified definition because of the many roles and responsibilities nurses have in a team.

As soon as a nurse sets foot in a clinical environment they are part of a wider team, whether that be the nursing team with other nurse colleagues, a deputy and ward sister/charge nurse or a ward manager, or with nursing associates and healthcare assistants. The wider team includes doctors of all grades, physiotherapists, radiographers, speech and language therapists and pharmacists, to name but a few. This wider team is referred to as the multidisciplinary team (MDT). Patients may need just a few members of that team, or all of them.

When it comes to patient care, nurses could be considered the hub of the team; they handle patient referrals to the MDT, and provide care and patient information. In some cases, they will need to liaise holistically and in a person-centred manner with both the patient and their family.

Although nurses have a key role in care, the most important person is, ultimately, the patient. If a team’s goal is for a patient to get better, there is no one more likely to be invested in this goal than the patient themselves (Rosengarten, 2019). Nurses are alongside the patient in this central role, often acting as their advocate when the patient is unable to fulfil this role themselves. This is highlighted in the section of the NMC’s (2018) Code on prioritising people, which states that nurses must “act as an advocate for the vulnerable” and “act in partnership with those receiving care”.

Complete the tasks in Box2.

Why is teamwork essential?

The healthcare environment is fast paced and rapidly changing: patients are living longer, often with more complex healthcare requirements, and there is a global shortage of nurses that has led to a higher demand for upskilling in areas in which this was previously not needed, including critical care, infectious diseases and the emergency department.

One person cannot carry out all of the necessary tasks in these interactions with patients, so there is a complex network of information sharing, communicating to and with all involved, being aware of the ever-changing situation and the availability of resources, as well as the need for documentation. If there is a breakdown in one of these components, the patient may not get the care they need, may not get the correct medication or advice for discharge, or, as a worst-case scenario, any necessary escalation resulting from their condition may not occur, leading to harm.

It has been recognised that teams that work well together and communicate effectively perform better and provide better patient care (Robson, 2016). Poor teamwork has been linked to an increase in the incidence of missed nursing care (Goh et al, 2020), including helping patients to mobilise, mouth care and communication with the patient about tests or procedures (Kalisch et al, 2011).

Linking back to the NMC’s (2018) Code, nurses should hold patient safety as paramount; when there is a breakdown in teamwork – especially in the communication component – patient care is directly and negatively affected. Student nurses should feel confident to:

• Use their communication skills to speak up;
• Ask questions;
• Be accountable for any errors they make by reporting them to appropriate staff;
• Challenge poor practice.

Key teamworking skills

Mickan and Rodger (2005) outlined six key characteristics that underpin teams in healthcare. These are:

• Common purpose;
• Measurable goals;
• Effective leadership;
• Effective communication;
• Good cohesion;
• Mutual respect.

These characteristics were reduced to four key attributes in a Team strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) training programme to improve patient safety and team effectiveness:

• Communication;
• Situational awareness;
• Leadership;
• Mutual support (Agency for Healthcare Research and Quality, nd).

There is an overlap between the two sets of characteristics, with the common goal being to maintain quality care and patient safety. It is important to recognise that these models summarise the overall characteristics of teamwork. The nurse’s role in a team takes many forms, such as care provider, teacher, advocate, communicator, leader, critical thinker, coordinator, delegator and innovator.

Communication and teamwork

Many patient safety incidents, complaints and negligence claims are related to communication between healthcare staff, or between staff and patients or their relatives (Robson, 2016). The ability to communicate effectively is often assumed but there are many factors that contribute to good communication. The NHS Knowledge and Skills Framework (Department of Health, 2004) cites communication as a core component for all employed staff. This includes:

• Active listening;
• Verbal and non-verbal communication;
• Keeping relevant people informed of progress;
• Documentation.

In a healthcare setting such as the NHS, the volume of information and how this is communicated is vast and can be a potential source of error if no guidance is set out. Various communication methods can be used to clarify the information delivered or received, and enable efficient communication. Three methods that are particularly useful are detailed below.

Closed-loop communication

This communication method is designed to reduce the risk of errors as a result of misunderstandings and wrong assumptions (Robson, 2016). An example of this type of communication is as follows:

Nurse 1: “Could you please do the vital signs of Mr Jones in bed 10?”

Nurse 2: “You want me to do Mr Jones in bed 10’s vital signs?”

Nurse 1: “Yes, that is correct.”

This shows that Nurse1, who has delegated the task, can be confident that Nurse2 understands the task – Nurse2 confirms that the task asked of her is to carry out the vital signs on Mr Jones in bed10, so there is no ambiguity. This helps to make sure the patient gets the correct care.

Readback

The readback method can be used during patient handovers. At the handover, the receiving nurse reads back the information given to them (for example, a past medical history, the most recent vital signs or the time that a procedure is occurring) to make sure it is correct. This can be confirmed by the nurse who has delivered the information, who now also knows that the nurse receiving the patient is aware of the care needed (Robson, 2016).

Situation, background, assessment, recommendation (SBAR)

The SBAR method is commonly used in the NHS and healthcare settings (Müller et al, 2018). It is used to communicate information in a structured way, such as when a patient is deteriorating and a nurse may have to escalate care to a member of the MDT. A second ‘R’ can be added to the SBAR acronym; it stands for ‘readback’, to confirm understanding (Haig et al, 2006).

Complete the task in Box 3.

Tool limitations

All these methods are important and useful for communicating change in a patient’s condition, but their application in improving day-to-day teamwork can be limited (Rosengarten, 2019). That is why communication is not used in isolation, even though it is, perhaps, the largest component of teamwork.

Leadership

Nurses should be able to step into a leadership role at any point in their nursing career. There is obvious apprehension from students or newly registered nurses: what if they are wrong? What will people say about them being the most junior member of the team? They may also be scared of putting themselves forward. However, the NMC’s (2018) Code states that nurses “should be a model of integrity and leadership for others to aspire to”. This process starts in the undergraduate years, should be nurtured throughout training, and then be ongoing during the person’s time as a registrant.

An effective leader:

• Accepts the leadership role;
• Appropriately calls for help;
• Constantly monitors the situation;
• Makes decisions;
• Inspires the team;
• Resolves conflicts (World Health Organization (WHO), 2011).

Mutual support and respect

It is vital that respect between team members is reached on a professional and personal level. Conflict in a team can lead to poor performance and poor outcomes for patients. McCabe and Sambrook (2014) suggested that, without mutual backup or support in a nursing team, a risk of missed care will intensify, compromising patient safety.

Throughout your professional career, there will be individuals with whom you may disagree, but remember: always respect a difference in professional opinion. This mutual respect extends beyond the nursing team to the roles of the MDT. It is crucial to understand the roles of each team member, their capabilities and their designated tasks. The other aspect of mutual respect is praise and gratitude. Praise among colleagues can boost morale as well as confidence, gratifying both yourself and the people around you, including your patients.

The NMC’s (2018) Code outlines how, as a registrant, poor practice should be challenged; this also applies to student nurses. By respecting your colleagues, but also understanding that patient care and safety are the priority, you should have the confidence to speak up and challenge any instances of poor practice.

“Poor teamwork has been linked to an increase in the incidence of missed nursing care”

Self-awareness and teamwork

Self-awareness is an important factor when working in a team. We often do not know how we will react to a challenging or stressful situation until we experience it. By reflecting on our behaviour, we can learn to become more self-aware. The NMC requires registered nurses to carry out reflection as part of their revalidation process every three years. However, reflection in healthcare is not confined to fulfilling this requirement, but is often used as a tool to develop understanding of thoughts, feelings or actions in particular scenarios.

On a more basic level, self-awareness can mean knowing that when you are tired and hungry, you feel more stressed. This can lead to potential errors or irritability, so it is important that you take regular allocated breaks, eat, hydrate and try to get adequate sleep before shifts. This can be difficult in busy clinical settings, but it is essential that you understand your own attitudes, behaviours and overall professionalism when experiencing these stressors, and that you are aware of how you are viewed by other team members.

Barriers to effective teamwork

Established teams often provide high-quality care; when those teams change, it can take time to re-establish the previous bonds and knowledge held. There may be a change in skill mix; for example, retirement can mean there is a loss of knowledge built up over decades. Short-staffing can lead to more junior or agency-based nurses working on unfamiliar wards or clinical areas, which can be challenging. Medical staff may rotate areas over the year and staff unfamiliar with the setting will need time to settle into it; this also applies to newly hired or newly qualified staff from all healthcare backgrounds.

WHO (2011) suggested the change in roles can be a barrier to communication. Nurses in the UK have seen many changes in their role over the past few decades; it has become more multifaceted, leading to an advancement of skills and greater responsibilities. Nurses with specialist training can now prescribe medication, perform some surgical procedures or advanced diagnostic tests, and run their own clinics. Traditionally, these specialist roles were medicine based and it can be difficult because roles that have transitioned to nursing may not initially be understood by MDT members.

Successful teams

Successful teams:

• Have received the correct training;
• Have a common goal;
• Use clear communication methods;
• Have a designated role that they and the other team members understand.

Cohesive teams have a unique, identifiable team spirit and commitment (Mickan and Rodger, 2005). For example, a cardiac resuscitation team is multidisciplinary with a common purpose to effectively resuscitate patients. Team members use simulated scenarios to be familiar with equipment, have up-to-date and appropriate training, and practise communication in their roles. Complete the task in Box 4.

Simulation is a key learning strategy. It allows students and staff to collaborate in a safe environment, and simulate scenarios that may occur in their own area of practice. It is a safe space, where no patients come to harm and a debrief can allow for constructive feedback, which can be applied in clinical practice. The learning strategy of simulation, debriefing and facilitated discussion is effectively being used to teach nurses competent teamwork (Barton et al, 2018).

It is vital that team members know their assigned role, and that others know what they do and can do. Start by learning names and job titles. Introduce yourself, and give your title as a student nurse, the year you are in and your capabilities. This is in keeping with the NMC’s (2018) recommendation to work within your limitations. In an emergency, it is better to ask ‘Robert’ to get 500ml of saline, knowing he can find it, than to ask ‘someone’ to get you the fluids. By not using specific names, you run the risk of losing valuable skills, as several people may leave to do the same task. Complete the task in Box 5.

Conclusion

Teamwork has many components – some are instinctive, and some take practice. Patient care and safety should be at the core of everything you do in healthcare. You will not know your strengths and weaknesses until challenged, but you can prepare to some degree through training, reflection and simulation.

Some key points to maintaining professionalism in a team are:

• Effective communication;
• Working within your own limitations;
• Self-awareness;
• Mutual respect and support for colleagues and patients.

Remember that your colleagues appreciate teamwork as much as you do, and will remember staff members who helped them when they felt overwhelmed or thanked them after a long, busy day. Try to think what the qualities are of a team member with whom you would like to work, and then embody these standards.