Successful Collaboration in Healthcare: A Guide for

Physicians, Nurses and Clinical Documentation Specialists

Visit the link below to download the full version of this book:
https://cheaptodownload.com/product/successful-collaboration-in-healthcare-a-gui
de-for-physicians-nurses-and-clinical-documentation-specialists-1st-edition-full
-pdf-download/
 1
Introduction

Keeping current in today’s ever-changing healthcare world can be

challenging for providers, staff, and organizations. Healthcare is not
maintained in a bubble but is affected by many aspects, including techno-
logy, regulations, and reimbursement. These are just some areas about
which healthcare workers must stay abreast. Technology seems to expand
faster than the average person can comprehend. Computers, e-mails,
cell phones, text messaging, and electronic imaging are examples of the
way technology impacts our lives. No sooner do we purchase a computer
system than it is replaced by something newer and more advanced. In
addition, technology has affected how we communicate. No longer is it
necessary to have face-to-face meetings when we can “meet” in a virtual
setting. This ability has allowed communication to occur across various
time zones without the need for travel, as well as for quicker dissemination
of information and for decisions to be made more rapidly. In addition to
the changes in technology, healthcare regulations and reimbursement are
frequently adjusted or amended. Considering technology adds to the abil-
ity to modify and distribute these changes, keeping current is even more
crucial. Physicians, nurses, and case managers are challenged by these
changes. Clinicians not only need to stay abreast of medical and scien-
tific aspects of healthcare, they also must understand and keep current of
how technology and regulations affect their roles. How does an electronic
record affect data entry and chart documentation? How do regulations
such as the Health Insurance Portability and Accountability Act of 1996
(HIPAA) affect these clinical roles as they need to share information while
maintaining compliance? How do physicians, nurses, and case manag-
ers keep current with government regulations and institute changes into
their workflows? These are just some of the questions one may ask when
1

TAF-K10656-09-0901-C001.indd 1 1/6/10 11:33:51 AM

 2 • Successful Collaboration in Healthcare

considering various changes in healthcare. However, clinicians should not

think they are alone in this challenge. Understanding different healthcare
roles and how they intertwine can help the process of keeping current
with change. Knowing, or at least partially understanding, others’ roles
can provide a resource for one’s own role regarding whom to go to with
questions and ideas. As clinicians in various roles collaborate, they can
successfully overcome the challenges found in healthcare’s dynamic set-
ting. Collaboration provides an opportunity for people in various disci-
plines to work together to create positive outcomes.
Many different types of healthcare providers, including physicians,
nurses, and case managers, can build an alliance that affects safe, quality
patient care and impacts finances positively through a variety of opportu-
nities. Nurses can work in various roles with physicians to provide quality
care while meeting the requirements of federal and state governing bodies
and considering the financial impacts to their organization. These nurs-
ing positions may include the direct patient caregiver, the charge or team
leader nurse, the case manager, and the clinical documentation special-
ist (CDS), a newly emerging role. Regulating and financial impacts may
include recovery audit contractors (RACs), present on admission (POA),
healthcare-acquired conditions (HACs), diagnosis-related groups (DRGs),
and value-based purchasing (VBP).
Building this alliance among healthcare workers requires more than
people doing their jobs. This partnership involves collaborating in a posi-
tive manner to achieve a goal or outcome. The concept of working as a
team is not new. We were taught to get along with each other as children.
We were told to get along with our siblings, friends, teammates, and even
possibly our enemies. We may have been taught by a good teacher or
learned by trial and error how to work together. The saying two heads are
better than one supports working together. How often have we struggled
to fi x something or learn a new process but are not successful until we
work together with someone else?
To understand how workers in various healthcare roles can collabo-
rate to become an effective team, one must first understand what consti-
tutes good collaboration. Communication is the basis for collaboration.
Effective communication is built on trust and respect. In addition, under-
standing another’s roles from his or her perspective facilitates commu-
nication. After one has an understanding of communication, one can
then apply that learning to improve quality and understand the financial

TAF-K10656-09-0901-C001.indd 2 1/6/10 11:33:52 AM

 Introduction • 3

aspects of healthcare. Understanding how communication links the vari-

ous healthcare roles helps one to understand how he or she can impact
these outcomes.
As mentioned previously, there are many types of healthcare roles:
physicians, nurses, case managers, and CDSs. Each discipline may carry
its own specialty, for example, physicians being internal medicine phy-
sicians, pediatricians, surgeons, and cardiologists. Nurses may vary
depending on units or specialties, such as medical, surgical, orthopedic,
critical care, emergency, obstetrics, or hospice nurses, or in roles such
as team leader, staff nurse, charge nurse, or director. Case managers
may be designated by different focuses such as hospital, disease man-
agement, worker’s compensation, and community-based case managers.
To confuse matters more, some organizations may call one discipline
one name, whereas another organization calls the same role or position
another name. Although organizations may use different names or titles
for various roles, it is the crux of the role that matters. What are the
functions of the role? What are the credentials? What is the experience?
How is the information applied? What is the process? These are aspects
to consider when deciding who is doing what job. Finally, after under-
standing the roles and potential impacts, one can see how the process
potentially fits together in a variety of situations. Being able to apply
information is crucial to understanding how healthcare collaboration
can be successful.
This book will provide a guide to understanding the clinical docu-
mentation role, including how it relates to nurse and physician roles.
Communication of physicians, nurses, and CDSs in the hospital setting will
be described as it relates to collaboration. Understanding aspects of com-
munication is the beginning of collaboration. In addition, understanding
and applying communication tools such as SBAR (situation, background,
assessment, and recommendation) will be described. Another aspect of
collaboration is understanding how people in different roles view infor-
mation through three types of knowledge: person, patient, and case.
After understanding communication, next comes the ability to
understand how quality and financial components inf luence the
roles of physicians, nurses, and CDSs. Surprisingly to some, qual-
ity and financial aspects can overlap in healthcare. Understanding
terms that relate to quality and finances, such as length of stay
(LOS), DRG, POA, and HAC, helps us begin to fit together the pieces

TAF-K10656-09-0901-C001.indd 3 1/6/10 11:33:52 AM

 4 • Successful Collaboration in Healthcare

of the puzzle. Explanation and application of these terms provide

additional opportunities for comprehension. However, the links do
not end here, as other pieces, including VBP and public reporting of
information, form part of the larger picture. Then, just when one is
able to complete the puzzle, the government revamps the picture to
include RACs.
As the complexity of healthcare has grown beyond understanding the
clinical and technical areas of taking care of patients to include financial
and quality concerns, the CDS role has emerged and is explained in greater
detail in Chapter 4. This role is more than someone policing physician
documentation. This role combines clinical areas with coding and regula-
tory concerns. It has grown as many hospitals have made it a permanent
program in their organizations. In addition, vendors also include this doc-
umentation role in their computerized systems. Although computerized
systems may help with the technical components, understanding the role
and the process is crucial for the success of the CDS position. In Chapter
4 the role is further explained as the CDS process is highlighted. In addi-
tion, the five reasons to query a physician are addressed. According to
the American Health Information Management Association (AHIMA),
these include “legibility,” “completeness,” “clarity,” “consistency,” and
“precision.”
Understanding why to query a physician helps complete the clinical pic-
ture. Just as one cannot judge a book by a cover, one cannot “see” the true
clinical picture of the patient until the picture is described completely,
clearly, and accurately. For example, the book may be titled Pneumonia,
but one does not know what the book is truly about unless it is further
described. Just as the title is not complete, a patient’s diagnosis of pneu-
monia does not adequately describe the patient. The pneumonia should be
further detailed, including the type, organism, comorbid conditions, and
other supporting information.
The CDS role does not end with documentation. Data collection helps
support how the role fits into quality and financial aspects of health-
care. In addition, the role is not for everyone. It requires the right mix of
education, experience, and communication skills. Education and train-
ing are vital for the CDS role; however, this education does not end with
the CDS. It must be expanded to include physicians and nurses because
the team needs to understand how they fit together. Education of the
role is an ongoing process as healthcare continues to experience changes

TAF-K10656-09-0901-C001.indd 4 1/6/10 11:33:52 AM

 Introduction • 5

in technology, regulations, and clinical information. Understanding the

process of change as it relates to education can facilitate the process.
Although this guide, including figures, tools, and scenarios, was designed
to cover the various aspects of the CDS role and healthcare collaboration
with physicians and nurses, the opportunities for change and growth con-
tinue to be part of healthcare. Keeping current with these changes and
incorporating them into an organization’s existing system and processes
are not only part of today but also of the future.

TAF-K10656-09-0901-C001.indd 5 1/6/10 11:33:52 AM

 2
Building Trust and Communication

Communication sounds like a simple task that should occur naturally.

However, this natural art does not come easily for everyone. In addi-
tion, the same can be said for collaboration through communication.
Whereas some people appear to work together and communicate easily,
others require more deliberate efforts. Building this collaborating alliance
through teamwork requires energy. Successful collaboration requires us to
have self-awareness. We need to know our strengths and weaknesses and
the potential impact they have on others. In addition, we need to know
and understand our communication style. Self-awareness of our commu-
nication style and behavior is an important step in understanding how we
present ourselves to others. To understand how people communicate, we
must understand some of the different communication styles.

COMMUNICATION STYLES
There are many styles of communication that one may observe when
interacting with different personality types. The topic of communica-
tion styles could be a book in itself; however, for basic purposes the main
four types focus on behaviors of aggressiveness, passive-aggressiveness,
passiveness, and assertiveness. These styles can build positive collabora-
tion or break down communication through negativity. Understanding
the differences in these styles can provide a basis for learning how to
communicate effectively.

TAF-K10656-09-0901-C002.indd 7 1/6/10 11:34:49 AM

 8 • Successful Collaboration in Healthcare

Aggressiveness
Aggressiveness has a negative connotation and may be described by words
such as “hostility,” “belligerence,” and “forcefulness” (Microsoft Encarta,
2006). The aggressive person may display an angry expression, including
a stern stance and a brazen voice that says he or she does not care about
the results as long as the person gets what he or she wants. The person may
have an uncompromising behavior and focuses on his or her own needs
instead of considering others. The aggressiveness may come in the form
of an outburst, leaving the remaining spectators startled and astounded.
The aggressive communicator may shout, “I want it fi xed, and I want it
fi xed now! I don’t really care how it is done—just do it or else!” Although
this outburst may seem extreme, the aggressive behavior makes the per-
son’s point known in a controlling manner. This bullying behavior does
not promote professionalism but rather adds tension to the environment.
People may be fearful of the person’s aggressive behavior to the point they
do not want to speak with him or her and further avoid any interactions.
This avoidance impedes future conversation because people may decide it
is easier to avoid the person than deal with the aggressive behavior.

Passive-Aggressiveness
Avoidance may also be seen when communicating with a person who is
passive-aggressive. The passive-aggressive style is demonstrated by the
person does not wish to communicate directly with another. Instead of
speaking with the person, the passive-aggressive communicator chooses
to interact indirectly. He or she manipulates by avoiding confrontational
issues. The passive-aggressive communicator may leave a message with
someone else to give to the person he or she is avoiding to keep from
speaking with the individual in person. This behavior may be seen with
someone who is fearful of another person’s reaction but still wants to
achieve his or her own result. Passive-aggressive behavior may also be seen
when a person sabotages another’s work or idea by outwardly appearing
as if he or she is going to support the changes or ideas but in reality does
not follow through with his or her commitments. An example would be
if the person agrees that a change to a work form is a good idea but later
tells others he or she does not plan to use it. Or the person may even tell
others not to use the form but denies what he or she said if asked. The

TAF-K10656-09-0901-C002.indd 8 1/6/10 11:34:49 AM

 Building Trust and Communication • 9

passive-aggressive person does not want to deal with conflict directly but
would prefer to use negative behaviors such as gossiping to get what he or
she wants or to express him- or herself (Zeiler, 2008). This type of behav-
ior may not be recognized as easily as the aggressive person’s behavior
because others may not realize it is happening immediately. However, as
the passive-aggressive behavior is demonstrated in a variety of settings
and situations, others may see the pattern and realize this person chooses
to avoid a situation directly. Instead, he or she allows others to deal with
the consequences of his or her actions in these difficult situations.

Passiveness
Passiveness may initially be seen in passive-aggressive behavior, but the
passive person tends to be more timid and puts other’s feelings, needs,
or desires first. This person wants to keep peace and will avoid confron-
tations. He or she will not “stir the waters” when interacting with oth-
ers. He or she may agree with everyone else regardless of his or her own
thoughts or opinions. Different from the passive-aggressive person, the
passive person will not comment or express his or her opinion. His or her
behavior focuses so much on what others want that the person may not
even ask or state what he or she wants. If the passive person does express
his or her own opinion, he or she does it in a safe environment. If the
response is negative, the passive person may not pursue any further com-
munication or requests. On a continuum, passive communication may be
at one end of the spectrum and aggressive communication at the opposite
end. When a passive person and an aggressive person interact, negative
results may exacerbate each other’s communication style. The passive per-
son becomes more withdrawn, and the aggressive person becomes more
forceful. Passiveness may not initially be considered a negative attribute;
however, because the passive person is not able to express him- or herself,
the results may be negative.

Assertiveness
A balance of the different aspects of communication styles may be seen in
the assertive style. Although the assertive person is not afraid to express
him- or herself as a passive person may be, he or she is neither hostile
nor belligerent as an aggressive person. Assertiveness is characterized by

TAF-K10656-09-0901-C002.indd 9 1/6/10 11:34:49 AM

 10 • Successful Collaboration in Healthcare

honest, open communication in a nonthreatening manner. Microsoft

Encarta (2006) defines assertive as being “confident in stating a position
or claim.” People who are assertive may speak using facts with a non-
defensive approach. They take ownership for their own thoughts and do
not put the blame on others. Although they are confident and know what
they want, they also have the ability to listen to others. This demonstrates
a safe environment and respect for both parties. Assertiveness represents
a positive communication style. Being assertive does not mean one knows
all of the answers or is always right. Being honest and admitting one does
not know the answer promotes positive interaction. This person acknowl-
edges he or she does not understand a concept or have the answer but is
willing to research the information, use available resources, or find out
who may help in the situation. This type of behavior promotes honest
communication.
Assertive communication is not just for people in positions of leader-
ship; it can also be used by nurses, physicians, and clinical documentation
specialists as they communicate information with each other. When we
consider the differences in communication styles, we may picture someone
who has characteristics of a certain style. However, we should remember
who is a role model for the assertive style so we can keep this picture in our
mind when we are communicating with others. Clear, honest, confident,
and nonthreatening communication can provide an effective medium for
sharing information and promoting collaboration.

ASPECTS OF COMMUNICATION
In addition to being assertive when communicating with others, one
should look for the “win-win” situation when possible. It is not a matter of
“us against them” or “who’s right and who’s wrong.” Part of communica-
tion is sharing information and not pointing fingers. Positive communi-
cation entails listening and considering different perspectives, presenting
information clearly and in a nonthreatening manner, and realizing that
although one may be confident with his or her ideas, there may be a bet-
ter solution or idea. When considering different solutions, the involved
parties should consider the main goals and desired outcomes. Where do
these overlap? What are the common areas the parties are focusing on?

TAF-K10656-09-0901-C002.indd 10 1/6/10 11:34:49 AM

 Building Trust and Communication • 11

What areas cannot be changed because of regulations or safety consider-

ations? What areas are desires but are not required? For example, everyone
may want a million-dollar budget for his or her department; however, if
this is not possible, one should determine what the mandatory, regula-
tory, or safety needs are. What are the “must haves” versus the “want to
haves?” Working together to achieve a common goal and desired outcomes
supports the win-win situation.
Achieving the win-win outcome may seem to be a simple task, but
it does not always occur. Even in a work setting, negativity can be dis-
played in aggressive or passive-aggressive behaviors. An example may be
demonstrated when a committee discusses changes in an organization.
The group may attempt to look for the win-win situation, but all parties
do not agree on the goals or outcomes. Although no one is directly aggres-
sive in the meeting, when it is over, the noise starts as disgruntled parties
express their opinions. This impedes productivity, as the conversations are
not expressed with the appropriate people who need to hear the informa-
tion. Instead, the discussion occurs where or when others who are not
concerned may hear. Although the information may reach the intended
group, the message may be completely distorted. This concept of error
when passing along information is similar to the childhood game of “tele-
phone” or “whisper down the alley.” One person starts the message and
whispers it to his or her neighbor who whispers it to his or her neighbor
until it goes around the circle and reaches the person who started the mes-
sage. By the time it reaches the original person, it is not only inaccurate,
it is also so distorted that the message does not even make sense. This can
occur when communication does not occur directly between all parties.

COMMUNICATION AND TRUST

Aggressive and passive-aggressive communication does not promote trust.
Although one may argue that an assertive person is not always trustful
either, the assertive person demonstrates respect. Trust and respect are not
equivalent, but they are two positive aspects when communicating. How
does one earn trust? One could say a person needs to respect the other
person to trust him or her or vice versa. Some characteristics that promote
trust are knowledge, accuracy, and follow-through. If someone falls short

TAF-K10656-09-0901-C002.indd 11 1/6/10 11:34:49 AM

 12 • Successful Collaboration in Healthcare

in any of these areas, trust may not develop. One may be very knowledge-
able in his or her field or career but does not always accurately present
information, thoughts, or ideas. In addition, the person may not follow up
on requests or projects. An example would be if the person is an expert
in critical care nursing but does not give the correct lab results or clinical
picture of the patient. Or the person may give the correct clinical picture
but does not follow up by calling the physician with an update as requested.
In contrast, the person may follow through with the projects, but the infor-
mation presented is inaccurate or not current. This can happen when a
person receives a request for a report from a committee. The person pres-
ents the report as requested, but the information is not accurate or current.
These situations do not establish trust among the others.

EMOTIONAL MATURITY
Another aspect of communication is emotional maturity. This incorpo-
rates understanding and controlling one’s own expressions, thoughts,
and behaviors while identifying and acknowledging others (Lindeke and
Sieckert, 2008). Emotional maturity may be demonstrated by express-
ing oneself in a sensible manner. This level of maturity does not end once
achieved. One cannot put it on a shelf and expect these qualities to fall into
place whenever he or she communicates with others. Without a conscious
effort to take control of one’s maturity, a person’s innate characteristics may
overtake the learned ones. This may be seen in a highly stressful situation
creating conflict. Conflict can cause stress, and stress can add to conflict.
This snowball effect may be seen as tension escalates. A person’s ability
to control his or her behavior and language is superseded by the tension
and frustration of the environment. The person loses control of his or her
emotional self. This may come in the form of yelling, making unrealistic
demands, or making an inaccurate assumption of cause and effect.
An example of emotional immaturity may be demonstrated when a per-
son wants a chest radiograph report “now” that has not even been done or
when a person assumes the reason the radiograph was not done is because
the computer system to order the test is outdated. When the person com-
plains, “I never get my test reports when I need them” or “Nothing works
right around here,” he or she is making generalized statements that are not

TAF-K10656-09-0901-C002.indd 12 1/6/10 11:34:49 AM

 Building Trust and Communication • 13

necessarily true. However, an emotionally mature person does not make a

generalized outburst but instead is able to analyze the situation. The person
realizes after speaking with the staff nurse he or she cannot get a report
on a chest radiograph “now” that has not even been done. It would also be
more accurate to state the person wants the chest radiograph done now.
In addition, complaining that the computer system is outdated may be an
incorrect assumption if the real reason the radiograph was not done was
because the x-ray room was not available at the time the test was ordered.
Although many of us have been in tense situations where time is cru-
cial for patient outcomes, expressing negative comments and rudeness
does not alleviate the stressful situation. Instead, this emotional outburst
may escalate the stress of the situation. Controlling one’s own emotional
behavior is not only important for the sender but also the receiver of the
message. How one responds can add fuel to the fire or extinguish the
flames. If the person does complain, “I never get my test reports when I
need them,” the responder should not argue back about the accuracy of
the statement. Maybe this statement was prompted because the patient
may be demonstrating signs of acute pulmonary edema with congestive
heart failure (CHF) and the physician wanted a chest radiograph to help
diagnose the condition. Patient care should be the priority in this situ-
ation and not the general statement of not getting reports. Instead, the
focus should be on what can be done to get the patient radiograph and
treatment he or she needs. After the patient’s care has been addressed, the
situation can be examined to determine whether processes are in place for
emergent situations. In addition, after analyzing the situation and looking
at potential processes, communicating results of the analyses and formu-
lating a process to help prevent the issue in the future can help clear up
the situation.

COMMUNICATION ASSESSMENT
Although communicating with emotional maturity may be the desire,
what happens when a person has attempted to communicate effectively
but another person still responds aggressively or does not respond at
all? These two frustrating situations can impede further communica-
tion. First, one should go back to the initial lesson of knowing one’s own

TAF-K10656-09-0901-C002.indd 13 1/6/10 11:34:49 AM

 14 • Successful Collaboration in Healthcare

communication style. Assess how the sender approached the receiver. One
may need to ask an objective party what he or she observed. What did the
objective person hear during the conversation? What was the tone? How
did the sender address the receiver? How did the receiver respond? This
may be difficult because a productive solution requires honest, construc-
tive criticism by the third party. In addition, the sender must be willing to
listen to the assessment. This step is not about who is right or wrong but
how the sender expressed his or her message. After hearing this analysis,
one can determine what he or she could have done differently. Next, one
should consider the environment in which the communication took place.
Was it in an appropriate setting? Should the conversation happen privately
or in a less public area? Was the tension of the environment appropri-
ate for the timing of the conversation? Asking about a scheduling conflict
with an employee during an emergent patient situation such as a cardiac
arrest is obviously not appropriate timing.
If the assessment was that the sender’s message and situation were
appropriate, then one should evaluate the response of the receiver. Ask the
third party how he or she perceived the receiver’s response. How one inter-
prets the response may be different than what actually occurred. This can
happen when the two people have had past difficulties with communica-
tion. One or both may feel the other did not respond properly; however, to
the objective observer, the conversation may have been appropriate. If the
receiver did respond aggressively or ignore the communication, then the
sender needs to determine his or her best response. The response should
focus primarily on patient safety. If the message is crucial to the safety of
the patient, then the sender needs to make sure the appropriate person
receives the communication. If one has attempted to communicate but is
unsuccessful, he or she should follow the organization’s chain of command
to get the information to the appropriate person. However, when the mes-
sage can wait or be delivered in another method, the sender should con-
sider his or her own response to the situation. Storming off with a rebuttal
or negative retort demonstrates the inability of that person in controlling
his or her behavior. Attempting to understand the receiver’s perspective
may be more beneficial. Listening is an important aspect of attempting
to understand another’s viewpoint. The receiver may have information
that the sender was not aware of. Keeping an open mind and being non-
judgmental may be vital in understanding the other’s perspective. In addi-
tion, being positive and stating facts clearly are constructive approaches

TAF-K10656-09-0901-C002.indd 14 1/6/10 11:34:49 AM

 Building Trust and Communication • 15

in conveying information. However, there are some circumstances when

the sender may have to calmly take a deep breath and continue with his or
her work. This is not about ignoring the conversation but realizing there
are times when it is advantageous not to contribute to a potentially hostile
situation. After assessing the circumstances, one should discuss the situa-
tion with the appropriate person outlined in the organization’s policy.

CODE OF CONDUCT
Communication is not limited to affecting just the two communicating
parties but can affect patient care. If there is a strain on communication as
seen with aggressive or passive communication or emotional immaturity,
the information required to take care of a patient may not be discussed
adequately or in a timely manner. If a person is too afraid to speak to
another provider about a patient’s condition because he or she is fearful
of being degraded or the receiver of the provider’s outbursts, the patient
may not receive the care he or she needs. If a staff member must call with a
change in a patient’s condition, but the receiver yells at the person, belittles
the caller’s input, or responds in other negative ways, the caller may avoid
calling the person in the future. Or the caller may provide only minimal
information so that he or she can get off the telephone quickly, avoiding a
negative response. Even if the receiver does not make any unconstructive
comments, the anticipation of fear from the caller may prevent the person
from staying on the phone long enough to answer all of the questions, give
a clear picture, or receive complete orders. Fear of inappropriate behaviors
or conduct should not impede patient care.
Inappropriate behaviors have escalated to a level of awareness that is rec-
ognized by The Joint Commission. In 2009, two aspects of a new leadership
standard speak to this issue. According to The Joint Commission, accred-
ited organizations need to have a “code of conduct that defines acceptable
and disruptive and inappropriate behaviors.” In addition, the leaders need
to “create and implement a process for managing disruptive and inap-
propriate behaviors” (The Joint Commission, EP 4 and EP 5, 2008). This
heightened awareness of the effects of behaviors in healthcare supports the
need for positive communication. No longer should it be acceptable to say
that doing excellent work is good enough to ignore bad behaviors.

TAF-K10656-09-0901-C002.indd 15 1/6/10 11:34:49 AM

 16 • Successful Collaboration in Healthcare

COMMUNICATION TEMPLATE
Even after using appropriate communication behaviors and establishing
an assertive style, the ability to effectively communicate does not end here.
The information needs to be presented clearly and accurately. Organizing
the information helps present this information clearly. If someone conveys
information in a disorganized ramble, the receiver may have to sort out
a jumbled mess. The sender’s words do not create a clear picture because
they are not arranged with any sense of order. This muddled information
should be presented in an organized format. One way to organize informa-
tion is by writing down the information in a specific arrangement. The idea
of organizing one’s thoughts through writing is not a new concept but may
not be obvious. How often in our daily lives do we organize our thoughts
through lists or a structured method? We write a grocery list. We create
a “things to do” list. We schedule our lives using a calendar or prioritize
our work in a visual format. Whatever our method, we have decided that
having our information structured helps us to stay organized. Likewise, a
template can help structure our thoughts so information can be presented
more clearly to the receiver. The communication template might include
headings or captions of certain data or material that needs to be presented.
These headings may include date, time, name or title, data, and outcomes.
They should be arranged in a logical order that will help the flow of infor-
mation. The type of communication template and headers will depend on
the situation for which the communication template will be used. If the
communication template is for a home project, it may look different than
a tool used in a healthcare setting such as a hospital.
In healthcare, the transmission of information is not just about organi-
zation but also about knowledge, accuracy, and trust, as these are crucial
for the patient’s safety and care. When a nurse calls a physician with a
change in a patient’s condition, the physician has to be able to trust that
the nurse is knowledgeable, giving accurate information, and will follow
through with the plan of care. According to Iacono (2003), physicians want
organized and factual information when communicating with nurses.
For novice employees, using a communication template may be helpful;
however, many experienced employees also can benefit from this tool. In
fact, The Joint Commission Accreditation recognizes communication as a
Hospital National Patient Safety Goal (2009). A communication template

TAF-K10656-09-0901-C002.indd 16 1/6/10 11:34:49 AM

 Building Trust and Communication • 17

can be created that supports information needed for the safe handoff of a
patient. The template provides the vital information needed for the next
person to safely take care of the patient.

SBAR: SITUATION, BACKGROUND,

ASSESSMENT, AND RECOMMENDATION
One communication template used in healthcare and supported by the
Institute for Healthcare Improvement (IHI) is communicating using the
acronym SBAR: situation, background, assessment, and recommendation
(IHI.org, n.d.). Each word is a heading in the communication tool that
provides a prompt of important reminders when communicating. What is
the situation that is being described to the person? What is the background
or history of the situation? What is the communicator’s assessment of the
problem, issue, or concern? What may be some recommendations or ideas
the communicator is thinking about? This tool can guide staff through
the process of knowing what is needed when conveying information to
another person. Imagine the difference of using SBAR versus not using
SBAR. See Scenario 2.1.
Although both conversations end with the same orders, the second
using SBAR provides a more complete, immediate picture for the physi-
cian. In the first scenario, if the physician would have not asked as many
questions, he might have not discovered the patient had congestive heart
failure. Not using a template such as SBAR may lead to incomplete infor-
mation, inappropriate orders, frustration, wasted time, and poor out-
comes. When the physician does not know the patient, which can happen
when the on-call physician is contacted at 2:00 AM, the outcomes may be
worse as frustration escalates.
In contrast, using SBAR provides a base from which to present infor-
mation in a logical format. In addition, it promotes critical thinking for
the nurse as he or she gathers information and goes through the thought
process. Providing accurate and factual information in an orderly fashion
promotes positive communication that can support trust. The logical for-
mat that SBAR uses can be applied to communication in many settings
and among various healthcare workers. This concept can be used when a
staff nurse gives an update to a physician, charge nurse, or case manager.

TAF-K10656-09-0901-C002.indd 17 1/6/10 11:34:49 AM

 18 • Successful Collaboration in Healthcare

SCENARIO 2.1
I. Conversation without SBAR
Nurse: Dr. Roe, this is Miranda from 3 East at the hospital. I have
a patient of Dr. Jans who is more short of breath this eve-
ning. His name is Mark Williams.
Physician: What was the patient admitted with?
Nurse: Well, he was admitted with pneumonia.
Physician: What are his vital signs? Has he been dyspneic with the
pneumonia, or is this worse?
Nurse: It seems worse. His temperature is 99.7, pulse 98, respirations
28, and blood pressure 145/89.
Physician: Is he wheezing? Does he have a nebulizer ordered?
Nurse: He just had a nebulizer treatment an hour ago. He does not
have any wheezes, but his lung sounds have bilateral crack-
les, and he has an oxygen saturation of 90% on 3 L/min. He
also has IV fluids at 125 cc/h.
Physician: Does he have any other health history? What is his urine
output?
Nurse: He has a history of congestive heart failure, and he has voided
100 cc in the past 8 hours.
Physician: Get a STAT chest x-ray and B-type natriuretic peptide
(BNP CHF), and give furosemide 20 mg IV. Decrease his
IV fluids to TKO (to keep vein open). Please call me with
an update of his condition, the chest x-ray results, and his
urine output from the furosemide within an hour.
Nurse: OK. I will get the STAT chest x-ray and BNP CHF, give furo-
semide 20 mg IV, decrease his IV fluids to TKO, and call
with an update within an hour. Thanks.

II. Conversation Using SBAR

Nurse: Dr. Roe, this is Miranda on 3 East at the hospital. (Situation)
I have a patient of Dr. Jans who seems more short of breath
this evening. His name is Mark Williams. (Background)
He was admitted with pneumonia 2 days ago and seemed
to be doing better, but this evening he is complaining of
being more dyspneic. He has a history of congestive heart

TAF-K10656-09-0901-C002.indd 18 1/6/10 11:34:49 AM

 Building Trust and Communication • 19

failure. (Assessment) His lungs have bilateral crackles. He

has an oxygen saturation of 90% on 3 L/min. He also has
IV fluids at 125 cc/h and has only voided 100 cc in the past
8 hours. Neither his abdomen nor bladder feels distended.
His vital signs are temperature of 99.7, pulse 98, respira-
tions 28, and blood pressure 145/89. (Recommendation)
I wonder if he needs his fluids adjusted.
Physician: It sounds like he is in failure from his CHF and extra IV
fluids. Has he had a chest x-ray or lab work today?
Nurse: He had a complete blood count this morning but no chest
x-ray since admission that only showed the pneumonia.
Physician: Get a STAT chest x-ray and BNP CHF, and give furo-
semide 20 mg IV. Decrease his IV fluids to TKO. Please
call me with an update of his condition, the chest x-ray
results, and his urine output from the furosemide within
an hour.
Nurse: OK. I will get the STAT chest x-ray and BNP CHF, give furo-
semide 20 mg IV, decrease his IV fluids to TKO, and call
with an update within an hour. Thanks.

KNOWLEDGE DIFFERENCES
Expectations of others may be a challenge with communication when
people have a variety of backgrounds, knowledge bases, and experience.
One may expect a person to know exactly what the other person wants.
The person may not understand why the other gives additional informa-
tion he or she does not feel important. This can be a challenge with com-
munication. Various roles in healthcare may affect how we collaborate as
people with different knowledge bases may focus on different viewpoints.
Liaschenko and Fisher postulate and describe three aspects of knowl-
edge as it relates to nursing: person, patient, and case (Stein-Parbury and
Liaschenko, 2007). Person knowledge refers to the ability of knowing the
person’s being, including how the person lives and fits into his or her sur-
rounding environment. Where does the patient live? How does the patient
get his or her medications? Who is available to support the patient? Patient

TAF-K10656-09-0901-C002.indd 19 1/6/10 11:34:49 AM

 20 • Successful Collaboration in Healthcare

knowledge refers to a patient’s comprehension and familiarity of his or

her disease and how he or she reacts to treatment. What does the patient
know about his or her disease process? How long has the patient had the
condition? Is the patient compliant with treatment when he or she is at
home? Both person and patient knowledge require communication with
the patient. In comparison, case knowledge focuses on the technical and
methodical aspects of the person’s disease and treatment. Case knowledge
emphasizes the scientifically objective information of a disease. What does
the patient’s chest x-ray show? What are the patient’s lab results? What
is the patient’s oxygen saturation? This information can be ascertained
while reviewing and applying clinical knowledge without potentially even
seeing the patient.
Whereas nurses may focus more on the person and patient knowledge
bases, physicians may concentrate on the case knowledge. This difference
in knowledge base may cause some disruption when nurses and physi-
cians attempt to communicate about a patient’s condition. Although all
three aspects may be important when considering the patient’s plan of
care, the person considering one set of knowledge may not think the other
set of knowledge is as important. For example, when a patient is admitted
with pneumonia, both the physician and nurse may be concerned with the
patient’s lung sounds and administering appropriate antibiotics. However,
the physician may be more interested in the white blood count (WBC)
and sputum culture results, whereas the nurse may be concerned about
the tolerance of activity. Whereas the physician may want to know the
oxygen saturation is 91% on 2 liters of oxygen, the nurse may interject that
the patient cannot get up to the chair without being dyspneic. In addi-
tion, the nurse may be concerned because the patient reports she has two
young grandchildren she baby-sits and is fearful of them getting pneumo-
nia from her. Although the physician and nurse may focus on different
aspects, their ability to collaborate for the benefit of the patient should
not be affected. When one considers the holistic perspective, the patient’s
WBC count, sputum culture, oxygen saturation, activity tolerance, and
fears are all areas to consider when working as a team for the benefit of
positive patient outcomes. Being able to integrate all three levels of knowl-
edge gives a clearer picture of the patient, the response to his or her care,
and future treatment plans.
Understanding and respecting different viewpoints can improve the
ability to communicate and work together. Even among various nursing

TAF-K10656-09-0901-C002.indd 20 1/6/10 11:34:49 AM

 Building Trust and Communication • 21

roles, one may have different perspectives of a situation. The nurse who
is the direct patient caregiver may focus on the patient’s assessment, the
initiation of intravenous therapy, and supplemental oxygen. The charge
nurse or team leader may be concerned with chart orders, following up
with lab and x-ray results, and staffing issues. The nurse as a case manager
reviews the patient’s condition and treatment plan according to approved
criteria, while also considering potential discharge plans and needs (see
Chapter 3). No one role is more important than another—they all are
part of taking care of the patient from various angles. Effective group
collaboration in this setting can embrace professionalism (Lindeke and
Sieckert, 2008).

WORKING TOGETHER
The different foci of knowledge can create different expectations and
challenges. Attempting to understand another’s point of view is helpful
for effective communication. In addition, both parties need to determine
the goals or outcomes of the situation. They need to realize that working
together is important in reaching these goals. Standards of practice or
evidence-based practice may help to align parties. Working together for
the common goal allows all parties to pool their resources and enhance
efficiency. In contrast, working independently may waste time and re-
sources, as each person works toward the goal without the other person’s
contribution.
In Figure 2.1, for example, one can see Persons 1, 2, and 3 are all work-
ing toward the same goal. However, because there are barriers, such
as each person receiving instructions from a different person or work-
ing in separate environments, the three persons may duplicate efforts,
thus wasting time and resources. In addition, even if the barriers were
removed, the people work toward the goal independently because their
lines of communication do not cross. If the barriers were removed and
the parties communicated, they could pool their knowledge, efforts,
and resources to achieve the goal more quickly and efficiently. See
Figure 2.2.
Although different perspectives and knowledge bases can be challeng-
ing as the team focuses on the common goal, these differences can broaden

TAF-K10656-09-0901-C002.indd 21 1/6/10 11:34:49 AM

 22 • Successful Collaboration in Healthcare

Goal

Person 1

Barriers

Person 2

Barriers

Person 3

FIGURE 2.1
Parallel actions without communication. Each person is going down his or her own path
heading in the same direction; however, the paths do not cross, and knowledge is not
shared. If there are additional barriers to the communication such as people working
on the same project but in different settings, they will not know what everyone’s role
is in the plan or if progress is being made. Each one may reach the common goal but
may have used more resources and time because they did not merge their knowledge or
resources.

the possibilities of how the goals are met. The plan is not restricted to
one mindset but rather enhanced by the variety of the others’ knowledge,
experience, and approaches. Ground rules may need to be set for a clear
understanding of expectations. Respect for each other while collaborating
is important for effective communication.

Goal
FIGURE 2.2
Parallel actions with communi- Person 1
cation. In comparison to Figure
2.1, Figure 2.2 demonstrates how
Barriers
if barriers are removed and each
person merges his or her paths, Person 2
the group can combine their
efforts, knowledge, and experi- Barriers
ences. As they communicate and
collaborate, the goal is reached Person 3
sooner, and potentially fewer
resources may be used.

TAF-K10656-09-0901-C002.indd 22 1/6/10 11:34:49 AM

 Building Trust and Communication • 23

NURSING ROLES AND COLLABORATION

Nurses have various roles and responsibilities in healthcare, includ-
ing direct nurse caregiver, charge nurse, or case manager. Collaboration
within these nursing roles is vital for successful patient care. The nurse
as the bedside caregiver may have different responsibilities and priorities
than the charge nurse or nurse case manager; however, the overall picture
should be the same. All should maximize their roles by using their knowl-
edge and experience to enhance collaboration. Each entity has a wealth of
information to share with his or her counterparts. Although these roles
may vary in different organizations, the concept of working together is the
important factor. The bedside nurse may be clinically savvy as he or she
performs a thorough assessment of the patient’s current condition apply-
ing his or her clinical knowledge. In addition, the bedside nurse has an
understanding of the technical needs as he or she critically thinks through
patient care. The charge nurse understands the staffing needs of the unit,
admissions and discharges, physician orders, and ancillary department
communication and provides leadership for a cohesive unit. The case
manager’s expertise includes understanding the dynamics of insurance or
other payer’s criteria, discharge needs of the patient, different levels of care,
and various social aspects. An emerging role that correlates with these
nursing positions is the clinical documentation specialist (CDS). Although
the CDS is not a nurse in all organizations, the role will be viewed from a
nursing perspective as described in Chapter 4. The CDS can integrate the
information found on chart review with the clinical picture of the patient.
Sharing this information with other disciplines provides a different but
important aspect of the patient’s overall status.

OTHER OPPORTUNITIES TO COLLABORATE

Opportunities to collaborate do not only occur within a specific role but
are part of working together as a team. An example of collaboration is
demonstrated when people work together to help each other. Collaboration
does not always need to focus on the clinical aspects of care but may occur
when someone needs help either asking for directions or finding a form.

TAF-K10656-09-0901-C002.indd 23 1/6/10 11:34:50 AM