A collaborative leadership has the influence to transform health-systems and healthcare organizations, improving the system today and for the future—to the benefit of patients, families, and caregivers. This issue of Lipid Spin is focused on the theme of “Collaborative Patient Focused Care: Ensuring the Patient Has Access to the Complete Healthcare Team.” The authors have done a terrific job in getting the message across that will remind you of your own successful collaborative efforts. The articles should act as a conduit between our actions and values that favor teamwork. Action plans through educational programs can do a lot to spread the message and teach basic skills necessary to promote effective communication.
Health professionals tend to work autonomously, even though they may speak of being part of a team. Efforts to improve health care safety and quality are often jeopardized by the communication and collaboration barriers that exist between healthcare professionals. Although every organization is unique, the barriers to effective communication that organizations face have some common themes. These communication barriers occur within disciplines, most notably between physicians and residents, physicians and nurses, surgeons and anesthesiologists, nurses and nurse managers, primary care providers and specialists and among subspecialists.
Even though doctors, nurses and other healthcare professionals interact numerous times a day, they often have different perceptions of their roles and responsibilities as to patient needs, and thus different goals for patient care. One barrier compounding this issue is lack of cultural sensitivity or cultural humility.
In some cultures, individuals refrain from being forceful and do not challenge opinions openly. Hence, it becomes very difficult for nurses from such cultures to speak up if they see something wrong. In cultures such as these, nurses may communicate their concern in very indirect ways. For instance, some cultures attribute specific meaning to eye contact, certain facial expressions, touch, tone of voice and nods of the head. Issues around gender differences in communication styles, values and expectations are common in all workplace situations. Sutcliff1 and colleagues concur that communication failures in the medical setting arise from vertical hierarchical differences, concerns with upward influence, role conflict, ambiguity, struggles with interpersonal power and conflict. Communication is likely to be distorted or withheld in situations where there are hierarchical differences between two communicators, particularly when one person is concerned about appearing incompetent, does not want to offend the other or perceives that the other is not open to communication.
In a complex lipid patient, there are many reasons to explore a collaborative care model. Patient’s poor adherence2 may be a result of a multidimensional phenomenon determined by the interplay of multiple factors. First, patient factors play a major role that include attitudes toward their medications, out-of-pocket costs, side effects, the complexity of their regimens, poor communication with their physicians and their own psychosocial and economic stressors. Second, physician factors play a part that include prescribing complex regimens, failing to adequately explain the benefits and side effects of a medication, not giving consideration to the patient’s lifestyle or the cost of the medications, having poor therapeutic relationships with their patients, and alteration in their priorities in favor of the burden of documentation in the electronic medical record that gives them little time for patient education. Finally, health care system factors impact nonadherence due to limitation of access to health care, using a restricted formulary or switching to a different formulary, and having high costs for drugs, copayments, or both.
In a study by McGinnis3, et al and another study by Cohen4 et al, both physician and patient education of the risk of accelerated atherosclerosis as well as the risk benefit ratio of statins were felt to be of great importance. Patients with lipid disorders do not live inside a bubble. Most Medicare patients have comorbidities such as uncontrolled hypertension, chronic obstructive pulmonary disease (COPD), gastrointestinal issues, anemia, chronic kidney disease (CKD) issues, cornary artery disease (CAD) with stents requiring multiple blood thinners such as dual anti-platelet therapy and requiring need of subspecialists. These patients may have CKD due to diabetes requiring the expertise of an endocrinologist, nephrologist and uncontrolled diabetes with need of newer agents that have a cardiovascular mortality benefit and myopathy that may be unmasked by a statin requiring the expertise of a neurologist. Dietitians, exercise physiologists and psychologists play a tremendous role in life style modification with personalized motivation and exercise prescription. Appropriate medication use and cost associated with out of pocket expenses, copays and other insurance related burden need to be addressed by pharmacy and social worker consult and teamwork.
Mechanic5 et al, in 1982, published an article describing opportunities for a cooperative agenda between doctors and nurses. Today, that subject matter is indeed still quite relevant. A powerful incentive for greater teamwork among professionals is created by directing attention to the areas where changes are likely to result in measurable improvements for the patients they serve together, rather than concentrating on what, on the surface, seem to be irreconcilable professional differences. The fact that most health professionals have at least one characteristic in common, a personal desire to learn, and that they have at least one shared value, to meet the needs of their patients or clients, is a good place to start. Browning and others have put together a Collaborative Healthcare Leadership6 white paper describing a six-part model for adapting and thriving during a time of transformative change. They conclude that a collaborative leadership has the power to transform hospitals and healthcare organizations, improving the system today and for the future—to the benefit of patients, families, and caregivers.
While collaboration is taking over the workplace in many situations, it also has its weaknesses. The distribution of collaborative work is often extremely lopsided. In most cases, 20% to 35% of value-added collaborations come from only 3% to 5% of employees. As people become known for being both capable and willing to help, they are drawn into projects and roles of growing importance. Their giving mindset and desire to help others quickly enhances their performance and reputation. But this “escalating citizenship,” as the University of Oklahoma professor Mark Bolino calls it, only further fuels the demands placed on top collaborators. We find that what starts as a virtuous cycle soon turns vicious. Soon helpful employees become institutional bottlenecks: Work doesn’t progress until they’ve weighed in. Worse, they are so overtaxed that they’re no longer personally effective. And often, the volume and diversity of work they do to benefit others goes unnoticed because the requests are coming from other national or international organizations or even multiple entities that need their expertise.
Appropriate continuing education on collaboration and teamwork needs to be included in the workplace. The focus should include themes such as sessions on team dynamics, communication skills, phone etiquette, assertiveness training, diversity training, conflict management, stress management, and any other courses necessary to foster more effective team functioning. Focused team training programs that foster an environment of trust and respect, accountability, situational awareness, open communication, assertiveness, shared decision making, feedback, and education, and interdisciplinary training have brought significant improvements to the sharing of information in the perioperative setting. This process can be emulated at multiple settings including the complex lipid patient.
Having a clinical champion/health coach/ nurse navigator as early adopter who actively promotes the importance of appropriate behavior, communication, and team collaboration can be a great asset. With trust, honesty and integrity, can we make a positive impact in empowering our patients? Can we create a sustainable impact through innovation in technology and investment in our own success, and be mission-driven through constructive partnerships? We can certainly provide the experience that conforms to the competency domain and guide them towards a progressive graded responsibility giving value, context and meaning to a doctor – patient interaction. And finally, I strongly believe that we can underpin our noblest traits that lie under the surface and deploy this knowledge to shape the delivery system through teamwork and collaboration.