In Creating an Effective Teamwork Culture, CNOs Are Key

Clinical collaboration is beneficial for the patient, staff, and the organization.

Elevated emphasis on patient-centered care has brought an increased awareness of teamwork in healthcare, and the chief nursing officer (CNO) plays a critical role in establishing and maintaining an effective teamwork culture, one nurse leader says.

"Establishing a team model that incorporates the core principles and works to modernize hospital/health system policy to authorize all clinicians to work to the top of their profession … are key for CNOs," says Sophia L. Thomas, DNP, APRN, FNP-BC, PPCNP-BC, FNAP, FAANP, president of the American Association of Nurse Practitioners. 

Research has shown that teamwork in healthcare—good communication, inclusivity, and awareness of other team members' responsibilities—leads to higher job satisfaction, better patient outcomes, reduced turnover, decreased healthcare costs, and, particularly in the current pandemic environment, less burnout.

"Effective teamwork occurs when all members of the team are bringing their best efforts and have the flexibility to use their expertise to achieve a common goal," Thomas says. "The hallmarks of effective teams—from players on a soccer field to the multiple disciplinary professionals in the ICU—is mutual respect and communication."

Some of the best teamwork examples she's seen include use of pastoral care in the ICU to lead discussions with families about a patient’s end of life; nurse practitioner (NP) school-based health centers where integrated behavioral health, dental, and primary care are all delivered in one setting; and senior care clinics where pharmacists meet with patients to co-manage medications, spot interactions, and discuss side effects along with the patients’ primary care nurse practitioner or physician.

Solid, effective teamwork is beneficial for the patient, clinical staff, and the organization as a whole, Thomas says.

The patient

"When deployed effectively, patient-centered, team-based care can lead to improved care coordination, increased patient/family engagement in care, improved outcomes, and decreased healthcare costs," Thomas says. "By integrating providers onto a care team who have relevant expertise to the patient’s needs, the patient benefits from more targeted and efficient healthcare delivery."

For example, a patient with complications from type 2 diabetes might benefit from the integration of a nutritionist onto the team to support healthful eating while a primary care provider manages the patient's medication and primary care needs, an ophthalmologist addresses ocular health, and a podiatrist ensures foot health and monitors for nerve damage.

"We need to do away with outdated care models, and [we need to] support efforts that put patients at the center of the team," she says. "This includes supporting teams that respect the perspectives and expertise of clinicians and other professionals most relevant to the patient’s health. With this kind of thinking, we can deliver culturally competent care that addresses the real needs of patients, while allowing NPs and nurses to strengthen patient outcomes and access to care."

Clinical staff

For clinical staff, effective teamwork brings increased job satisfaction and, particularly in the current environment, reduced incidence of provider burnout, Thomas says.

"When clinicians are working within a well-coordinated and multidisciplinary team, they have strong lines of communication with other healthcare professionals, mutual accountability for shared clinical outcomes, and a network of support," she says. "These are the ingredients that improve job satisfaction, which reduces burnout and—most importantly—delivers strong outcomes for patients."

Burnout is a major issue for clinicians nationwide; a pre-COVID-19 report by the National Academy of Medicine shows that 35%-54% of bedside nurses and physicians experience severe symptoms of burnout. The added burden of COVID-19 has created even more of a burnout crisis.

Effective teamwork can counterbalance burnout rates, Thomas says.

"Studies have shown that when providers are working in environments that support their ability to speak up about challenges, have their viewpoints and concerns acknowledged and acted on, are respected as equal partners in the care of patients, and are authorized to bring their full complement of knowledge and skill to their patient care, burnout risk is lessened," she says. 

The organization

At the organizational level, integrated, multidisciplinary care teams can result in less staff turnover, higher patient outcome and patient-satisfaction scores, and increased provider investment in overall patient outcomes that lead to improved care, she says.

"An example shared by one of our members was related to orthopedic joint replacement," Thomas says. "Instead of each clinician focused only on their task—the surgery, the physical therapy, the wound care—the team took overall accountability for joint health, recovery, and infection prevention. The rates of complications and lengths of stay decreased, and patient outcomes improved."

Matching the team to the care is important, she says. "Not every element of care requires a multidisciplinary team," she says, "but incorporating core principles of teamwork can apply to cross-systems care and care transfers, too."

Actions outside of hospital walls also are supporting teamwork in healthcare settings, such as the growing number of states—of which Massachusetts is the latest—that allow NPs to practice independently.

"I was on a call recently with NP leaders from Minnesota and Nevada who have had full practice authority for nearly a decade. Each shared how the flexibility under full practice authority created added opportunities and how the removal of bureaucratic links made way for more meaningful communication, coordination, and referral," she says. "By adopting full practice authority, Massachusetts joins a growing list of states that encourages all of its clinicians to work to the top of their profession, creating teams that are built to put patients—not a subset of clinicians—first."

Breaking down silos

In recent years, many in the healthcare industry have called for an increase in teamwork and a breakdown of traditional professional silos. Nurses, and other healthcare workers, dealing with the COVID-19 crisis helped break down those silos through necessity.

Natalia Cineas, DNP, RN, NEA-BC, senior vice president and system chief nurse executive at NYC Health + Hospitals in New York, says tackling the pandemic calls for teamwork both inside and outside the nursing profession.

"It's changed the whole notion of what 'type' of nurse you are. The whole specialty aspect went out the door," she says. "During COVID, if you were an ambulatory nurse, you would help [with] inpatient care. If you were with the Department of Defense—Army, Navy, Air Force—they came to help inpatient. If you were a Department of Education nurse, like a school nurse, you came, and you helped. I think it changed the whole notion of, 'That's that type of nurse, or they work over there.' I think it's solidified the fact that we're all one profession. Although you have to socially distance, we've become closer than we've ever been."

Thomas echoes this sentiment.

"One commonality I've found in all my conversations is an unprecedented sense of comradery and unity among all healthcare providers, which has been nice to see," she says. "Another one that's been welcomed is the increased level of incredible innovation and cooperation among the providers throughout the COVID response."

For example, NPs went to help in New York when Gov. Andrew Cuomo signed an executive order that allowed them to practice without a collaborative practice agreement.

"We immediately had 4,000 nurse practitioners go for temporary assignments in New York, and as they care for patients, they share critical information about the virus," Thomas says. "The information sharing has allowed NPs in all the types of care settings to better respond to COVID cases, whether they experienced an uptick or not."