attitude, collaboration, communication, leadership, nurse managed clinic, nurse practitioner, teamwork
A Phillips. Realistic Team Building in a Nurse Managed Clinic Setting. The Internet Journal of Advanced Nursing Practice. 2008 Volume 10 Number 1.
Teamwork is an essential element in any healthcare setting. A great healthcare team achieves success through elements of skillful work, shared vision, positive attitudes, and respect of each teammate. This paper discusses teamwork as a practice management issue within a nurse managed clinic. Clinical staff development, advanced practice nurse leadership, fundamental areas of high-quality teams, common problems with teams, and possible solutions are included. The four key characteristics of quality teams: effective leadership, positive attitudes, successful collaboration, and efficient communication are emphasized throughout this article.
Team development is important for every organization. Team work builds great champions. Every championship team has an excellent spirit of teamwork. Teamwork is defined as a group of people working cooperatively to achieve shared goals  . Teammates strive for success with competent skills, respect for one another, and dynamic synergy that promotes the best from each member  . Teams consist of motivated people who work together, share resources, are committed to common objectives, and through coordinated efforts produce a service far superior to that of an individual alone  .
In a health care setting, individuals from different areas come together to care for patients. Therefore, team building in today’s healthcare environment is important to improve morale and staff retention  . Teamwork is vital for large organizations such as the Ford assembly line, and also for large and small medical practices, such as a nurse managed clinic (NMC)  . NMCs led by an advanced practice nurse (APN) trained as a nurse practitioner (NP) provide high quality, safe, cost-effective care with a high level of patient satisfaction  . A NMC is a great healthcare team that achieves success through the elements of skillful work, shared vision, positive attitudes and respect of each teammate. One challenge for a NP leader at a NMC is making sure everyone believes they are a part of the team and contribute to clinic successes  . This paper will discuss teamwork as a practice management issue within a NMC. The review of literature throughout the paper examines the reasons team building is necessary for staff development, the four key areas of high-quality teams, common problems with teams, and possible solutions.
As a practice management issue within a NMC, teamwork and staff development are essential. A goal of staff development is team building as clinic staff are all members of the same team. The staff of a clinic need to be able to work together to handle the changes and stresses present in healthcare today. One component of staff development is coaching. Just as a NP coaches individual patients, the leader of a NMC will need to coach staff members. Coaching includes mentoring, challenging, and active listening to staff members  . Mentoring is a responsibility that is crucial to NP leadership  .
The NP leader of a NMC can become a formal or informal mentor. An example of formal mentoring, such as precepting, includes working with a NP student. This type of mentoring would have the support of a university, objectives, and a mentoring contract  . Informal mentoring is unstructured and usually long term  . An example of this type of mentoring includes a working relationship between a staff registered nurse and the NP leader. This form of mentorship assists the mentee in setting and achieving work or career-focused goals. Good mentors can foster growth and inspire the staff of a NMC to become more confident in their work  . Coaching and mentoring staff through transitions is rooted in the practice of an APN  .
Coaching also involves developing a shared vision among all staff members. The staff of a NMC should be actively involved in developing the vision of the clinic. A vision builds trust, collaboration, interdependence, motivation, and creates a mutual responsibility for success  . By clarifying a vision of where the clinic needs to be, a culture conducive to change can be created, and staff members will become empowered to work together as a team  . In such a culture, the relationships of all team members are caring and supportive  . According to Spross  , coaching involves cognitive, affective, behavioral, physical, social, and spiritual aspects. In the process of delivering care, the NP is coaching patients, families, staff, colleagues, and even themself  . The most common factors noted in retention of nurses are job satisfaction, a positive working environment, and good staff relationships  . Therefore, team building through coaching goes hand in hand with the development of staff within a NMC practice.
The goal of every high quality NMC team is to optimize the use of information, people, and resources to achieve the best clinical outcomes for patients  . In order to meet this goal, teams must have four key characteristics: effective leadership, positive attitudes, successful collaboration, and efficient communication  . Teams consisting of these key components create an atmosphere of mutual trust and expertise. A cohesive team will have effective communication, successful collaboration, and mutual support for each member  . A distinguished team within a NMC setting should also have a competent leader.
According to the literature, leadership provides the foundation for each team. An effective APN leader must have the basics of integrity, flexibility, loyalty, confidence, accountability, and self-discipline  . These basics start with the leader and extend to the individual team members, and then to the team itself. Leadership develops a sense of working together in a framework of mutual trust for the common good of the team  . APN leadership involves the ability to coordinate the activities of team members by ensuring team actions are understood, changes in information are shared, and team members have the necessary resources to deliver quality patient care  . An APN as a leader can use any one of many models of leadership to develop a personal leadership style.
Spross and Hanson  list some useful models of transformational leadership and change. Some of these well known models include: Values Centered Leadership Model by Secretan  ; Good to Great by Collins  ; and Cultural Transformation in Health Care by Kimball  . Since a NP as leader lays the groundwork for a successful NMC, one model of leadership that is appropriate to be practiced is The Fifth Discipline by Senge  . The relevant concept of this leadership model implies that an APN leader must commit to lifelong learning  . The five practices associated with leadership include: personal mastery in which the APN would continually redefine and clarify a personal vision; being aware of mental images that influence views of advanced practice nursing; developing a shared vision and sustaining the vision; suspending personal assumptions and listening to other’s viewpoints; and the fifth discipline allows the NP to see the whole picture rather than the isolated parts  . The model includes concepts that will allow an APN to become an effective team member, empower others and facilitate change to create effective learning opportunities  . An APN can use the concepts of the model to improve their own personal leadership goals  . The fifth discipline described by Senge allows the APN to view advanced practice within the overall context of healthcare and approach a healthcare team with a style that fosters cohesion and collaboration  .
An effective NMC leader has confidence, awareness of personal strengths and weaknesses, and the drive and self-respect to get the job done  . An effective leader will seek out a positive environment that will encourage all team members to learn and contribute. A positive environment in turn will foster cohesion, collaboration, and will ultimately help to create an excellent team  . A great NMC healthcare team is additionally made up of teammates who all exhibit a positive attitude.
Attitude is considered an internal state that influences a team member’s decision to act in a particular way  . The literature indicates that positive attitudes toward teamwork and a mutual trust among team members are critical to successful team processes  . An APN that fosters a positive attitude in employees will allow development of the capacity to work together as a team and overcome obstacles. Great teams have no place for attitudes that create an unpleasant environment. With a positive attitude, team members will become comfortable in addressing issues among themselves, problem solving together, and resolving conflicts  . According to Nicholson  , the key to a successful team is in finding the right people.
The hiring process is the most important task a NP leader has. By including staff in the interviewing process, applicants will know if they will fit in the work environment  . A positive attitude can not be taught to an employee, but can be fostered. Skills can be taught, so those who apply for a job with positive attitudes will be easier to work with than those with negative attitudes and good skills  . By allowing the staff to be involved in the selection process, the entire team will take ownership of the task of helping the new employee to be successful  . Effective team performance within a NMC requires positive attitudes and a willingness on the part of each team member to collaborate for a shared goal.
The terms teamwork and collaboration are often used interchangeably. Successful collaboration is a vital phenomenon to healthcare providers and patients. Collaboration within a healthcare team is a complex process that requires intentional knowledge sharing and joint responsibility for patient care  . The level of collaboration that takes place among healthcare team members can directly impact patient outcomes. A NP leader within a NMC will be prepared to play a central role in establishing a well functioning healthcare team; will lead the team, as well as participating in the work of the team. The lack of collaboration in a healthcare team may be responsible for as much as 70% of the adverse events reported in clinic settings  . According to Spross and Hanson  , the art of building strong relationships with others and staying connected with colleagues is basic to the sense of community needed to effectively lead a healthcare team. Successful collaboration among teammates will then lead to efficient communication.
Efficient communication is crucial to teams. Communication is accurately defined as an exchange of information among team members  . The literature indicates that communication and supportive interpersonal relationships have been consistently linked with positive attitudes toward the work environment leading to job satisfaction, improved job performance, and increased employee retention  . Staff communication and job satisfaction before and after receiving team-building interventions were examined in a study by Amos, Hu, and Herrick  . The team building interventions incorporated in the study included: identifying communication styles; improving listening skills; and reducing stress in the healthcare setting. The long term benefits that were recognized following the study include: improved listening and communication skills; addressing conflicts directly; improved job satisfaction; and decreased staff turn over rates  .
A NP leader must have impeccable listening and communication skills. Communication skills permeate every team interaction and every team intervention. The NP must be able to read the daily situations the clinic team members are involved in, and pick up on nonverbal cues and behaviors of the team members. By using listening and communication skills, a NP will be able to progress through day to day team management.
A NP within a NMC must also have the ability to communicate openly, clearly, and convincingly, both orally and in writing  . An APN leader within a healthcare team will encourage all team members to work toward efficient communication  . A NMC healthcare team should have regular and frequent team meetings. One example is arranging weekly team huddles to discuss any issues from the previous week, or just have time for brainstorming ideas. A successful NMC should also have an agreement on communication between team members. One strategy for such an agreement is to have team members establish rules for communication. When each staff employee abides by agreed upon communication rules for the group, a sense of trust and cohesion is fostered. An excellent healthcare team consists of the four key characteristics: effective leadership; positive attitudes; successful collaboration; and efficient communication detailed above and will then be able to achieve the best patient outcomes.
Since health care is a very demanding profession, many problems within a close working team can occur. The barriers to effective teamwork can be narrowed down to problems in the four areas described above: leadership, attitude, collaboration, and communication  . A breakdown in any of these four areas can create issues needing to
be resolved. The common problems occurring in these areas are explained below, followed by possible solutions.
The NP leader has the responsibility to plan, coordinate, and monitor the group’s activities and to convey a vision which inspires team collaboration  . An experienced NP leader at a NMC sets the overall tone for the group. If the NP is inexperienced in leadership, the vision and goals of the team may not be understood and therefore proper communications may not occur  . Consequently, the trust between team members can be damaged. A leader who does not have the trust of team members is set up for failure. In turn, this lack of trust can lead to poor communication among the entire team. Because perception is reality, poor collaboration follows. If the team members do not understand the goals and vision of the team as conveyed by the leader, appropriate changes and improvements may be difficult  . As a result, positive attitudes of team members and the leader may not be maintained.
The attitude of all team members involved has an overall effect on the entire NMC. Attitude is usually at the root of conflict  . Team members with a poor attitude can have difficulty in accepting constructive feedback in a positive, nondefensive manner and in expressing viewpoints  . This type of team member is often a low performer, unwilling to collaborate fully, has poor communication skills, and becomes terrritorial  .
Problems with collaboration and communication are the two biggest barriers to effective teamwork. As individual team members and the NP leader begin to work more closely together on shared vision and goals, inevitably, conflict will arise  . When poor collaboration exists a lack of trust among team members occurs. Trust is the key to successful collaboration and efficient communication  . A team member who does not trust other team members or the leader will have a lack of accountability  . Change in the workplace can also create difficulty with effective collaboration and successful communication. Even a small change can challenge a well working team. Conflicts between team members and the leader will not be resolved and will be disruptive to the group as well as to the entire teamwork process. When change exists conflict and resistance may continue to exist  . Patients may become aware of the constant conflict in the clinic and can begin to distrust the healthcare team as well. As a result of conflict, the entire healthcare process of the NMC may suffer  . A team with altered collaboration, communication, poor attitudes, and distrust is in need of an approach to rebuild these four key areas.
The NP leader recognizes the presence of conflict and needs to have some general approaches to conflict negotiation and resolution. These strategies are interconnected, and build upon each other. The recommended strategies are focused on the four key areas outlined in this paper: leadership, attitude, collaboration, and communication.
According to Jackson  , every professional wants to work with a staff comprised of enthusiastic, competent, motivated and dedicated employees. To create this group of individuals, an effective leader is vital. An effective NP leader of a NMC should improve personal professional development by becoming involved in a peer group  . A peer group can provide advice and instruction on the challenges of a growing healthcare practice  . A local NP organization, a state organization such as Texas Nurse Practitioners, or national organization such as American Academy of Nurse Practitioners can provide such peer group support. In addition to peer group involvement, the NP leader must build a clinic environment based on mutual trust. Trust is the highest form of human motivation. The team members must know that they can trust the leader, and the leader can trust the team members. A strong leader builds a team of self-sufficient, empowered, motivated, and valued employees. A strong leader has a clear understanding and commitment regarding expectations  . For overall team development, team members must be individually selected to fill in any gaps in skill sets  . An individual selection process allows team weaknesses to be complemented by another team member’s strength. The NP leader must identify each staff member’s talents and strengths and cultivate those talents. A creative response to conflict will be able to transform the problem into creative opportunities.
The NP as an effective leader clearly communicates what needs to be accomplished in the job and focus on what needs to be done, not on how  . Communication with employees should be open and honest. The NP leader should be respectful and professional, and listen intently to employees  . Standards of performance should be communicated clearly along with consequences for good and bad outcomes. Employee meeting times should be planned and positive and constructive feedback given  . The NP should map out any conflicts to define the issues needed to solve the problem and develop options for solutions with employees  . A bottom line needs to be identified and communicated to employees with a decision on what is negotiable and non-negotiable. By acknowledging employees’ thoughts and feelings, being cooperative and direct, conflict resolution will be easier  . By the NP leader demonstrating a commitment to this type of process, the team members will feel support and a foundation of trust will be initiated  .
Collaboration is also important in a team environment. Creating an environment in the workplace that fosters connection and commitment among workers is important in job satisfaction  . A cohesive team can compensate for other frustrations in the work environment. Teamwork in the healthcare setting enhances communication and listening skills. The art of conflict resolution is fostered with a spirit of collaboration as well  .
Conflict resolution is an essential skill for any team leader  . Any differences in attitudes towards tasks or responsibilities can create conflict. Conflict can also arise from differing goals of team members. As a result, conflict when viewed in a positive context, provides employees with critical feedback  . As stated by Porter-O’Grady  , embracing conflict will result in building a healthy community. A NP leader in a NMC setting will create a framework for negotiating dialogue among employees to uncover any issues needing remedy. When all team members contribute, a positive outcome will result from the conflict  .
The literature indicates that positive attitudes in the workplace have favorable outcomes. In a NMC, a positive attitude exhibited by the NP leader will in turn filter down to employees and patients. The use of positive and constructive feedback improves overall job satisfaction and also advances listening skills and communication within staff members  . Satisfied team members will do a better job  . A fun working environment will motivate employees positively and will decrease staff turnover  .
Humor in the clinic setting can decrease stress, help to retain staff, and serve as a survival tool  . Laughter is a coping mechanism, and can motivate employees toward top achievement  . Some suggestions to create fun in the NMC are: having an ice cream sundae party; celebrating a staff member’s birthday with a crown and a scepter; and creating a humor board to post appropriate funny cartoons, pictures, or newspaper clippings  . As the clinic staff begins to have fun, the more enthusiastic, creative and innovative the employees can be. Happy people treat others well, and become more satisfied  . If employees know their purpose, feel as though they are providing worthwhile work, and believe they can make a difference each day, patient and staff satisfaction improves as well  .
In conclusion, as discussed in this paper, effective team building can clearly enhance a NMC practice. As a practice management issue, building a successful team is essential for staff development within a clinic setting. This paper has discussed the four key areas of quality teams. The critical nature of effective leadership, positive attitudes, successful collaboration and efficient communication is emphasized. A quality team within a NMC practice can increase employee satisfaction and reduce turnover while improving quality of care, patient satisfaction, and patient outcomes.
The author would like to thank Susan Ruppert, PhD, RN, ANP-BC, NP-C, FCCM, FAANP for her critical review of this manuscript and her assistance in editing. Her kind words and encouragement were needed and very much appreciated along the journey.
Angela Phillips, MSN, RN, FNP-BC West Texas A&M University Health Partners Clinic 4400 S. Washington Ste. 107 Amarillo, TX 79110 Phone: (806) 355-5721 Fax: (806) 355-5775 firstname.lastname@example.org