|
|
Vol. 55, No. 12, December 2009, pp.1216 - 1222 Copyright © 2009 by The College of Family Physicians of Canada
Mechanisms for communicating within primary health care teamsJudith Belle Brown, PhDProfessor at the Centre for Studies in Family Medicine at the Schulich School of Medicine & Dentistry and at the School of Social Work at King’s University College at The University of Western Ontario in London
Laura Lewis, PhD
Kathy Ellis, MSc
Moira Stewart, PhD
Thomas R. Freeman, MD MClSc FCFP
M. Janet Kasperski, RN MHSc CHE
Correspondence: Dr Judith Belle Brown, Centre for Studies in Family Medicine, The Gordon J. Mogenson Bldg, 100 Collip Circle, Suite 245, UWO Research Park, London, ON N6G 4X8; telephone 519 858-5028; fax 519 858-5029; e-mail jbbrown{at}uwo.ca Communication is a hallmark of effective team-work.1–5 Exemplary communication optimizes team interaction and effectiveness.6 Furthermore, effective communication between and among team members has been linked to improved patient outcomes and patient safety.7,8 Teams use both informal and formal mechanisms for communication. Informal means of communication include, for example, "hallway consultations" and placing "sticky notes" on charts or computer screens.9 Formal mechanisms of communication include regularly scheduled team meetings, for both clinical and administrative matters, and documentation through minutes and memorandums.10–12 Drinka and Clark10 underline the importance of delineating specific tasks to be accomplished before, during, and after team meetings, such as creating an agenda before the meeting with the appropriate individual assigned to each agenda item, having all personal electronic devices turned off during meetings, and agreeing on an action plan during the meeting for follow-up afterward. Of 8 factors related to team effectiveness, Higgins and Routhieaux12 emphasize regular team meetings and clearly delineated team plans. Bridging both formal and informal means of communication within primary health care teams (PHCTs) is the growing use of medical informatics, including the electronic health record and computerized messaging systems.13,14 The latter promotes the timely and efficient transfer of information for both clinical and administrative issues among team members.15 Improving the flow of information, as well as access to information, can serve to improve the quality of communication within the team and thereby improve patient care.16 As PHCTs grow in size and scope of practice, communication will become more complex.15 Therefore, instituting effective mechanisms of communication on the team will be essential to ensuring coordinated and timely patient care, as well as administrative efficiency.15 Given that communication is considered the hallmark of effective teamwork, what do today’s primary health care professionals view as the key ingredients of and important barriers to successful communication within their teams? This paper examines the mechanisms for communication PHCTs are currently using and what members of the PHCTs perceive to be the successes and challenges of communication in their teams.
This was a descriptive qualitative study using in-depth interviews to collect data from a range of health care professionals working in primary health care teams.17 The data were collected in the province of Ontario between August 2004 and October 2005.
Sample selection and recruitment Several sampling techniques were used to recruit participants. Potential teams were identified through a number of sources, including a list of FHGs and FHNs provided by the Ministry of Health and Long-Term Care; a list of all of the CHCs in the province, supplied by the Association of Ontario Health Centres; and a list of FPTUs identified through academic departments of family medicine in Ontario. Potential participants were first mailed a letter of information outlining the study, which also indicated that each participant would receive a $75 gift certificate for his or her participation. Seven to 10 days after the letter was mailed, the practice sites were contacted by telephone to determine if they were interested in participating.
Data collection
Data analysis
Ethics approval
Final sample and demographics
Four themes emerged from the data regarding the means and mechanisms used to communicate on PHCTs. These included formal communication (eg, team meetings, agendas, meeting minutes and memorandums, computer-assisted communication, and communication logs); informal communication (eg, hallway consultations or chats and sticky notes); attributes that facilitated both formal and informal communication (eg, approachability, availability, and proximity); and funding issues related to communication (Table 1).
Formal communication Team meetings were viewed by participants as fundamental to their formal communication process and as an opportunity to engage all members in a consensus-building process. At team meetings we discuss problems or things that we think need to be addressed. Everyone puts in their two cents regarding the problem. We operate on consensus and solve issues and make sure that everybody is okay with the decision that is made. Having both regular and scheduled team meetings was also seen as important. Regularly scheduled team meetings provided a venue to discuss issues relevant to the team and to problem solve about clinical and administrative issues. If there’s something that needs to be instituted or brought in practice-wide, we’ll do it through those meetings and then we’ll send minutes of the meeting so that everyone is aware of what was discussed because not everyone can attend. Participants also agreed that agendas and minutes of team meetings assisted in organizing and documenting the team’s activities and decisions. One participant commented, "I make an agenda ahead of our discussions of what everyone’s concerns may be and we voice our opinions and try to work things out for ourselves." Minutes taken at meetings served as documentation and guided the direction of future action. "At the monthly meetings there are minutes taken and [the minutes are] referred to over the course of the following weeks." Memorandums served as another means of communication among team members to relay urgent messages ("If there was something urgent I would send a memo") or to provide updates ("The doctors send a lot of memos. They send them to every team member about something in public health or current issues that are happening"). Although computer-assisted communication is relatively new to these teams, it was endorsed by most participants. They saw it as a more efficient means of communication that was less vulnerable to human error. The computers have become a really good communication device because [there is] a messaging system on the [electronic medical record]. So instead of having a whole bunch of little slips of paper with messages on [them], which sometimes get lost, they’re listed in the computers .... You don’t have to worry about where you put the piece of paper. Computer-assisted communication was also viewed as a means of sharing information more quickly: "With our computer system we have a wonderful message system where we can relay the messages and ask questions and then they reply that way." However, participants spoke frankly about the strengths and weaknesses of e-mail communication. E-mail communication allowed for transparent documentation, efficiency, and objectivity: "It has to do with documentation and making sure that it is in writing, and in some instances it is more time efficient and it keeps the emotional aspects out of it." On the other hand several constraints with regard to e-mail use were voiced by front-line staff who felt that they, in comparison to the doctors and nurses on the team, did not have sufficient time available to use e-mail effectively. We’re front line so computer access for e-mail is quite restricted. You seldom have time to sit and read a full e-mail .... so, e-mails for me are failing us as secretaries. Doctors and nurses can shut their door in between clients. We don’t have enough time. As these individuals had limited time to check their e-mail they relied on "grapevine communication" to alert others to essential e-mail messages. "We don’t always have time to check our e-mails ... so what happens is one person will see it and then pass it to the rest and then everybody’s checking their e-mails." Finally, there were team members who were "not computer savvy" or who were perceived as being "afraid of the computer" and "not tenacious enough to figure it out," as they did not view it as "a priority." Another important form of formal communication, which was more profession-specific, was the use of "communication logs" to transmit information about patient care issues. Communication logs were essential where team members held part-time positions or were job-sharing and rarely had face-to-face contact. "The nurses keep a log book so that we can jot things down and communicate important information to the nurses who are not here every day. That way nothing gets missed."
Informal communication When face-to-face communication was not possible, "sticky notes" became the medium of communication: "Say a doctor is in with a patient, we’ll just stick a note on the door and say ‘Come see us, this has to be done.’" As one participant described, there could be a plethora of "sticky notes" on a given day: "Little notes attached to the computer or here, there, and everywhere." Another participant stated: "The sticky notes—they’re my lifesaver!" Many participants observed how the chosen method of communication reflected each team member’s individual style or preference for a specific medium of communication. Each of us has our own style of communication. Some of us still like to have sticky notes on the charts; some of us prefer to have the computer with the flashing message light telling us that there’s something that we should be attending [to].
Team attributes facilitating communication Approachability reflected team members’ comfort and ease communicating with other members of the team. "If something is urgent that I want immediate action on, I find them and talk to the person .... Everybody’s very approachable and you can talk to anybody, anytime." The attribute of availability was often assigned to team members with more authority or seniority who promoted an open-door policy. "My door’s always open and there’s always someone coming in and chatting about something." Proximity to one’s colleagues was also highlighted: "We sit across from each other, so she would basically tell me if she thought there was something I should know." Proximity facilitated communication: We share an office, so we’re talking constantly, there’s lots of back and forth to the front of the office, and the staff are in and out of our office ... catching us between patients and saying "I need to talk to you for a second."
Funding issues If anything we don’t have enough time to sort of work together. Because it’s really busy so our team meetings are pretty much crammed, and we don’t have as much time for the reflection that we like to have.
The study findings revealed the formal and informal means of communication used by PHCTs, as well as specific team attributes that facilitated communication. A considerable barrier to improving means and methods of communication on PHCTs was inadequate funding. Study participants identified regularly scheduled team meetings as a vital mechanism for communication on the team. This builds on findings reported in previous studies.5,12,21,22 Craigie and Hobbs21 have described team meetings as a safe place to raise issues and to participate in a problem-solving process that is both respectful and collaborative. This can serve to build cohesive teams and to develop creative strategies to sustain teams when they are confronted by stressful situations or conflict.22 However, meetings themselves can be a source of stress if inadequate time and remuneration become an issue.23 Furthermore, the location and timing of meetings can create tension among the team, particularly when certain agenda items are viewed by some members as mundane or not relevant to their roles.24 One means to avoid some of these issues is to conduct clinical and administrative meetings at separate times.11 When this is not feasible, it is important to create distinct agendas for each component of the meeting, including identification of the leadership or chair of designated agenda items. Teams must collectively agree upon required mandatory attendance by all members or identify which meetings are pertinent to specific groups only.11 These issues need to be addressed for optimal communication to occur. While the uptake of the electronic health record is still relatively low in Canada, the potential for this means of team communication is yet untapped and might indeed replace the "sticky note."25 Study participants’ views on the use of computerized communication were mixed and might reflect tension between early adopters and those individuals who lack computer skills or demonstrate minimal interest in this mode of communication.25–27 For teams staffed by numerous part-time members who rarely had opportunities for face-to-face interactions, use of communication logs was important. This ensured smooth transfer of information about both patient care and administrative tasks. Only one other study in primary heath care6 has reported similar findings regarding the use of communication logs by part-time team members; hence this mechanism warrants further exploration as a key communication tool in PHCTs. Informal communication dominated the daily interactions of the participants as they described working together as a team. Communication about patient care issues needs to be immediate. Ellingson9 has described this as "backstage communication," which occurs outside of formal team meetings and is essential to the provision of patient care. Hallway consultations might remain the preferred means of communication for clinical and business matters that are time sensitive. As PHCTs grow in size, however, the hallway consultation might not be an effective communication strategy for administrative or organizational matters, although they might remain critical for core team communication about patient care. Hence, the accessibility and proximity of team members is essential, as our participants identified. Approachability, as described by our participants, extends previous work in the literature.21 New funding models for PHCT’s, such as family health teams in Ontario, might eliminate concerns regarding remuneration and permit all team members, in particular family physicians, to be adequately compensated for their attendance at and participation in team meetings, both clinical and administrative. In addition, alternative financial arrangements might offset the costs of implementing computerized communication and therefore facilitate uptake of medical informatics, which have the potential to be an important communication medium.
Limitations
Conclusion
This project was supported by the Ontario Ministry of Health and Long-Term Care. The views expressed in this paper are those of the authors and do not necessarily reflect the views of the Ontario Ministry of Health and Long-Term Care. Dr Stewart is funded by the Dr Brian W. Gilbert Canada Research Chair.
Contributors Dr Brown oversaw the implementation of the study, including data collection and analysis, conducted the literature review, and wrote all drafts of the manuscript. Dr Lewis collected the data, contributed to the analysis and interpretation of the findings, and assisted with writing the manuscript. Ms Ellis oversaw the technical aspects of the data analysis and contributed to the interpretation of the findings and the final manuscript. Dr Stewart contributed advice on the implementation of the study and assisted with editing the manuscript. Dr Freeman and Ms Kasperski were responsible for the original idea, designed the larger study from which this paper emanated, and reviewed final versions of the manuscript. None declared This article has been peer reviewed.
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
TOP
METHODS
FINDINGS