Teamwork, Teams, and Reality

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In the October 2008 issue, Kathy Vestal, our Lessons Learned columnist, discussed the current environment surrounding the concept of team. It was amazing to consider that people have confused the idea of functional nursing with the concept of team. In the era of functional nursing, I recall an assigned medication nurse, bed bath aides, and—believe it or not—even a Pap smear nurse. This latter role was during the era when a pap smear was legislated for all female admissions in Illinois. Can you imagine having your pap smear done by someone you have never seen before in an assembly line fashion?

What about the nurse assigned to this task? It reminds me of the articles on factory workers during the industrial revolution. These employees spent their working hours on one repetitious task designed to streamline processes and enhance specific expertise. What was not considered was the level of boredom and lack of motivation that employees experienced, which resulted in various negative outcomes.

Today and particularly in the past 20 years, the concept of teams in patient care is more holistic. Teamwork is designed around the patient to ensure that those with the most expertise for particular needs are involved with the patient and the team responsible for the patients' care. One of the best examples of this is hospice, which I recently experienced firsthand with my mother. Hospice deploys teams to enhance the holistic approach for the patient and family while ensuring delivery of compassionate and skilled care. The hospice team incorporates a physician, several nurses prepared at different academic levels, a social worker, and chaplain. All of them remain on the same team to establish working and collegial relationships. Team communication and coordination are paramount and consistently practiced.

We have noted multiple times that there is much to learn from the business world. Many articles and books have been written in the business literature on the pros and cons of teams. It is worthwhile to explore them and to recognize that one size does not fit all, what works in one setting may not work in another.

It is also important not to confuse teams and teamwork with the abortive attempts at patient-centered care that occurred in many hospitals in the 1990s. The initial concept was to have the patient at the center of care with a team of experts delivering the necessary services according to patient acuity and needs. Although some patients may not have required the judgment and expertise level of a professional nurse at all times, the nurse was still involved in directing nursing care. What emerged from the “patient-centered care” rage unfortunately focused on replacing the RN with less prepared individuals. This was never the intent. The original design was to ensure that all professionals/staff were accountable for their actions to an individual, usually the professional nurse. One advantage was to allow the nurse to spend her time and energy on tasks and processes that required her skill.

How that plan evolved into substituting RNs doesn't amaze me as much as it should have. Many administrators saw this as an opportunity to reduce costs. The long-term result had extremely negative outcomes, often at the expense of the patient, nursing staff, and the organization. It did not take a futurist to see that the results would be disastrous in terms of recruitment, retention, lower patient satisfaction, and ultimately quality; this was validated by groundbreaking research.

Fortunately, that decade is history and the lessons learned are being used today. This includes the importance of maximizing staff and providing environments for professionals so that they can apply their education and skills while working with others who can provide caring services under the RN's direction.

Effective teams, where nursing is the primary requirement for care, must be led by professional nurses who make rounds, know their patients, and deliver care that requires judgment based on evidence-based practice, learning, and well-grounded experience. Using their skill level appropriately, while working with others to carry out tasks that do not require their expertise, is just common sense. I have maintained that inappropriate use of professionals is demoralizing as well as costly. It wastes their time and energy and is not motivating. My timing may have been completely off, but I still believe that continuity where team members work together is ideal, requiring the professional nurse's leadership. In addition, implementation of essential processes to enhance information sharing, input, and appropriate and timely use of resources can only enhance success for the patient, professional, and organization.

Ken Blanchard stated it well when he said, “None of us is as smart as all of us.”