Running head: TEAMWORK AND COLLABORATION

Enhancing Teamwork and Collaboration through Simulation Learning

Michelle A. Stimson
Ferris State University

TEAMWORK AND COLLABORATION

Abstract
Communication breakdown between healthcare providers leads to adverse patient outcomes
(Beckett & Kipness, 2009). Effective communication is the cornerstone of safe, patient-centered
care. Teamwork and collaboration can be difficult to achieve as many healthcare providers have
been educated in silos and did not develop effective communication, collaboration, and conflict
management skills in their formal education (Sherwood & Barnsteiner, 2012). Simulation
learning in the acute care setting can enhance teamwork and collaboration skills as well as
improve one's ability to communicate effectively in interprofessional teams (Lucas, 2014).

TEAMWORK AND COLLABORATION

Enhancing Teamwork and Collaboration through Simulation Learning

To Err is Human, initiated sweeping change throughout the healthcare industry in the
domains of quality improvement and patient safety (Sherwood & Barnsteiner, 2012). The report,
commissioned by the Institute of Medicine (IOM), exposed the dangers of America's flawed and
fragmented healthcare system (Sherwood & Barnsteiner, 2012). Adverse patient outcomes are
often the result of communication errors (Beckett & Kipness, 2009). Effective communication,
teamwork, and collaboration can be difficult to achieve because healthcare education occurs in
silos (Sherwood & Barnsteiner, 2012). Simulation learning can enhance teamwork and
collaboration skills and improve the communication in interprofessional teams (Lucas, 2014).
The purpose of this paper is to explain the role of simulation learning in the acute care setting
and how it can enhance patient safety, teamwork, and collaboration.
Teamwork and Collaboration Impacts Quality and Patient Safety
Industries such as nuclear power and aviation have far surpassed healthcare in quality
improvement and safety outcomes (Chassin & Loeb, 2013). Healthcare faces many complex
issues. Healthcare roles are intertwined and hierarchical challenges still exist (Chassin & Loeb,
2013). Healthcare professionals are educated in silos and few have learned effective teamwork
and collaboration skills (Barnsteiner and Sherwood, 2012). In order to achieve high quality
patient outcomes, healthcare professionals must work in teams. Working in teams can be
difficult. Nurses and physicians are taught different communication styles and few have learned
how to resolve interprofessional conflict (Beckett & Kipness, 2009). Both issues impede mutual
respect and patient safety (Manojlovich et al., 2014).
Realizing the severity of communication errors, The Joint Commission (2008) made
effective communication among healthcare providers a National Patient Safety Goal in 2009.
Communication errors are the root cause of 70% of sentinel events (Beckett & Kipness, 2009).
Effective interprofessional communication, teamwork, and collaboration reduces errors and leads

TEAMWORK AND COLLABORATION

to better patient outcomes (Lomax & White, 2015; Wagner, Liston, & Miller, 2011). Nursephysician relationships directly impact patient outcomes. Lower 30-day mortality rates have
been found in hospitals with better nurse-physician relationships (Ulrich, Lavandero, Woods, &
Early, 2014).
A new role has emerged for nurses over the past decade (Sherwood & Barnsteiner, 2012).
Healthcare leaders desire nurses with strong communication, collaboration, and problem solving
skills (Sherwood & Barnsteiner, 2012). Sparrow Hospital in Lansing, Michigan is no exception.
As large tertiary-care healthcare organization, it seeks nurses with the knowledge, skills, and
attitudes (KSAs) identified by the Quality and Safety Education in Nursing (QSEN) initiative
(Sparrow Health System, 2014). A large percentage of Lansing Community College nurse
graduates start their employment at Sparrow Hospital. Twenty percent of 400 nursing students at
(LCC) disagreed or strongly disagreed with the following statement after a simulation exercise:
"I am more confident in communicating with the interdisciplinary team" (LCC, 2015). It was the
lowest scoring item on a twelve question survey demonstrating the need for further teamwork
and collaboration education beyond the pre-licensure learning environment.
High Reliability Organizations, Just Cultures and Quality Improvement Models
A high reliability organization (HRO) is an organization fraught with risk, but has
adopted a culture that mitigates it (Chassin & Loeb, 2013). Safety issues are addressed while
they are small and manageable (Chassin & Loeb, 2013). High reliability organizations live in a
constant state of safety surveillance (Chassin & Loeb, 2013). They reward and celebrate the
identification of errors, potential hazards, and near misses (Chassin & Loeb, 2013). These type
of organizations emulate just cultures. In a just culture, employees feel free to speak up without
penalization (Graban, 2009). Errors are reported, acknowledged, and addressed (Graban, 2009).
Systems are established to catch errors and near misses. Safety is approached proactively rather
than reactively (Graban, 2009).

TEAMWORK AND COLLABORATION

Lean organizations focus on reducing waste and improving quality (Graban, 2009).
Healthcare has limited resources, so measures that reduce waste are imperative to its
sustainability (Graban, 2009). Prolonged lengths of stay and medication errors are examples of
waste (Graban, 2009). One key Lean principle involves solving small, unit-level problems by
the staff who do the work (Graban, 2009). Deferring to individuals with the most expertise in
the area of concern as a way to define or solve problems is a characteristic of Lean organizations,
HROs, and just cultures (Chassin & Loeb, 2013; Graban, 2009).
Sparrow Hospital has adopted just culture, HRO, and Lean principles. Safety briefings
occur daily and during all meetings. They allow front-line staff to report potential safety
concerns to persons of authority without fear of reprisal or punishment (IHI, 2004). Sharedgovernance occurs at the unit-level. It allows caregivers to address quality and safety issues by
the people who do the work. In the Heart and Vascular Center, front-line nurses decreased no
shows for scheduled procedures by calling patients ahead of time. They also improved patient
satisfaction and decreased safety risks by clarifying NPO status. CEO open forums and Lean
training occur monthly. They are well publicized and staff are encouraged to attend.
Nursing Turnover, Job Satisfaction and Simulation Learning
The environment in which nurses work is critical to job satisfaction, retention, and patient
outcomes (Ulrich et al., 2014). Job dissatisfaction and nursing turnover are associated with
medication errors and healthcare associated infections (Ulrich et al., 2014). Approximately one
third of nurses under the age of 26 plan to leave their job within the next two years (Wieck,
Doles, & Landrom, 2010). Younger nurses tend to have less satisfying relationships with
physicians (Wieck et al., 2010). The quality of nurse-physician and nurse-nurse relationships are
strong predictors of job satisfaction and retention (Aiken, Clark, Sloane, Lake, & Cheney, 2008).
Learning the skills of collaboration and teamwork can improve turnover, job satisfaction, and
patient safety by enhancing working relationships amongst caregivers (Aiken et al., 2008).

TEAMWORK AND COLLABORATION

Simulation learning is recommended by the IOM, the Carnegie Foundation, and QSEN
as an effective teaching strategy for enhancing teamwork and collaboration skills (Aebersold &
Tschannen, 2013; Sherwood & Barnsteiner, 2012). Although typically used in academia,
simulation can be used for education in the hospital setting (Galloway, 2009). Simulation
learning can reduce interprofessional role uncertainty and can improve communication between
disciplines (Lucas, 2014). It can also be used as a recruitment and retention tool. Increasing the
engagement and self-confidence of employees has been correlated with improved job satisfaction
and decreased turnover (Lucas, 2014). High-fidelity simulation is the most effective form of
simulation because it mimics real-life experiences (Lucas, 2014). However, role playing and
educating disciplines together are also acceptable ways to teach teamwork and collaboration
skills (Galloway, 2009; Sherwood & Barnsteiner, 2012).
Nurses in residency and fellowship programs are ideal candidates for simulation learning
focused on teamwork and collaboration. Many nurses within these programs are younger, recent
graduates, and are at a high risk for turnover (Vahey et al., 2004). These programs are structured
with didactic and clinical learning experiences and provide a captive audience for trialing a new
learning technique. Sparrow Health System offers both nurse residency and fellowship programs
(Sparrow Health System, 2014). The programs run several times per year over a twelve to
sixteen week period. Ideally, simulation exercises would be high fidelity, multi-disciplinary, and
include scenarios based on communication, teamwork, and conflict management skills.
Currently, Sparrow Health System does not have a simulation laboratory that could provide those
experiences. However, LCC does and it is nearby. Less high-tech options include watching and
responding to video vignettes created by TeamSTEPPS (ARHQ, 2014). Participants would view
video vignettes of ineffective teamwork and communication and participate in discussions

TEAMWORK AND COLLABORATION

regarding solutions. Djukic et al. (2012) had positive results after taking a similar approach with
medical and nursing students.
Ethical Implications for Nursing
For centuries, the profession of nursing has been a leader in quality and safety reform.
Florence Nightingale, the founder of modern nursing, collected data on hospital conditions and
correlated her findings with patient outcomes (Montalvo, 2007). As an altruistic profession,
nursing abides by a code of ethics (ANA, 2015). The Code of Ethics originated in the late 1800s
demonstrating nursing's longstanding relationship with moral and ethical principles (ANA,
2015). According to the code, professional nurses are responsible for protecting their patients
from harm and injury (ANA, 2015). They also have a professional responsibility to initiate
change that leads to high quality, safe patient care (ANA, 2015). Furthermore, nurses are the
largest group of healthcare professionals as well as the most trusted. Since 1999, Americans
have consistently rated nursing as the most trusted and ethical profession (Riffkin, 2014).
Research has demonstrated that interprofessional collaboration leads to higher quality
patient care (Lucas, 2014). Because nurses spend the most time at the bedside, they are typically
the link between patients and other disciplines. Unresolved conflict and breakdown in
communication compromises patient safety (Manojlovich et al., 2014). Knowing this, nurses
must play a role in managing conflict and communicating effectively with all caregivers.
Simulation learning can reduce interprofessional role uncertainty, improve self-confidence, and
enhance teamwork and collaboration skills (Lucas, 2014). Even though many healthcare
professionals may not have mastered these skills, nor see value in them, nurses are morally
obligated to do what is right for the patients they serve. Nurses can role model these behaviors
to other caregivers and open the lines of communication between disciplines. It is morally and
socially imperative that nurses facilitate the creation of care environments that do no harm

TEAMWORK AND COLLABORATION

(Sherwood & Barnsteiner, 2012). By developing effective communication and collaboration
skills and also learning how to manage conflict, nurses can ensure patients receive care in
environments that are safe and free from harm.
Conclusion
Without collaboration, a climate of patient safety cannot be established. No one
discipline has all of the knowledge needed to promote safe patient outcomes. Effectively
working in interprofessional teams reduces deficits, redundancies, and errors. Lack of
transparency and reports of patient harm within healthcare have eroded consumer trust. Who
better than nurses to lead the way forward? They are trusted, respected, ethical, and properly
educated to stimulate change and improve environments of care. In fact, it is their professional
and moral obligation to do so. Simulation learning enhances teamwork, communication, and
collaboration skills. Many nurses did not learn these skills in their pre-licensure education.
Gaining the skills needed to communicate effectively within teams and form collaborative
relationships allows nurses and other disciplines to work together in order to deliver safe, highquality care, and maximize patient outcomes.

TEAMWORK AND COLLABORATION

References
Agency for Healthcare Research and Quality [AHRQ]. (2014). TeamSTEPPS 2.0 video training
tools. Retrieved from http://www.ahrq.gov/professionals/education/curriculum-tools/
teamstepps/instructor/videos/index.html
Aiken, L. H., Clark, S. P., Sloane, D. M., Lake, E. T., & Cheney, T. (2008). Effects of hospital
care environments on patient mortality and nurse outcomes. Journal of Nursing
Administration, 38(5), 223-229.
American Nurses Association [ANA]. (2015). Code of ethics for nurses with interpretive
statements. Retrieved from http://www.nursingworld.org/MainMenuCategories/
EthicsStandards/ CodeofEthicsforNurses/Code-of-Ethics-For-Nurses.html
Aebersold, M., & Tschannen, D. (2013). Simulation in nursing practice: The impact on patient
care. The Online Journal of Issues in Nursing,18(2). Retrieved from http://www.
nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/
TableofContents/Vol-18-2013/No2-May-2013/Simulation-in-Nursing-Practice.html
Beckett, C. D., & Kipnis, G. (2009). Collaborative communication: Integrating SBAR to
improve quality/patient safety outcomes. Journal for Healthcare Quality,31(5), 19-28.
Chassin, M. R., & Loeb, J. M. (2013). High-reliability health care: Getting there from here.
Retrieved from http://www.jointcommission.org/assets/1/6/ Chassin_and_Loeb_0913_
final.pdf
Djukic, M., Fulmer, T., Adams, J. G., Lee, S., & Triola, M. M. (2012). NYU3T: Teaching,
technology, teamwork. A model for interprofessional education scalability and
sustainability. Nursing Clinics of North America, 47, 333-346. doi: http://dx.doi.org/
10.1016/j.cnur.2012.05.003
Galloway, S. (2009). Simulation techniques to bridge the gap between novice and competent
healthcare professionals. The Online Journal of Issues in Nursing,14(2). Retrieved from
http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/O
JIN/TableofContents/Vol142009/No2May09/Simulation-Techniques.html

TEAMWORK AND COLLABORATION

10

Graban, M. (2009). Lean Hospitals. New York, NY: Taylor & Francis Group.
Institute for Healthcare Improvement [IHI]. (2004). Safety briefings. Retrieved from http://
www.wsha.org/files/82/SafetyBriefings.pdf
Joint Commission on Accreditation of Healthcare Organizations [JCAHO]. (2008). 2009
national patient safety goals for hospitals. Retrieved from http://www.stvhs.com/student/
east/12%202009%20National%20Patient%20Safety%20Goals.pdf
Lansing Community College [LCC]. (2015). Spring 2015 student evaluations. [Handout].
Department of Nursing, Lansing Community College, Lansing, MI.
Lomax, S. W., & White, D. (2015). Interprofessional collaborative care skills for the frontline
nurse. Nursing Clinics of North America, 50(1), 59-73. doi: http://dx.doi.org/10.1016/
j.cnur.2014.10.005
Lucas, A. N. (2014). Promoting continuing competence and confidence in nurses through highfidelity simulation-based learning. Journal of Continuing Education in Nursing, 45(8),
360-365. doi:10.3928/00220124-20140716-02
Manojlovich, M., Kerr, M., Davies, B., Squires, J., Mallick, R., & Rodger, G. L. (2014).
Achieving a climate for patient safety by focusing on relationships. International Journal
for Quality in Healthcare, 26(6), 579-584.
Montalvo, I. (2007). The national database of nursing quality indicators (NDNQI). The Online
Journal of Issues in Nursing, 12(3). doi: 10.3912/OJIN.Vol12No03Man02
Riffkin, R. (2014). Americans rank nurses highest on honesty, ethical standards. Retrieved from
http://www.gallup.com/poll/180260/americans-rate-nurses-highest-honesty-ethicalstandards.aspx
Sherwood, G, & Barnsteiner, J. (2012). Quality and safety in nursing. West Sussex, UK: WileyBlackwell.

TEAMWORK AND COLLABORATION

11

Sparrow Health System. (2014). Sparrow nursing annual report 2014. Retrieved from http://
www.sparrow.org/upload/docs/about%20sparrow/sparrow%20nursing%20annual
%20report%202014.pdf
Ulrich, B. T., Lavandero, R., Woods, D., & Early, S. (2014). Critical care nurse work
environments 2013: A status report. Critical Care Nurse, 34(4), 64-79. doi:
10.4037/ccn2014731
Vahey, D. C., Aiken, L. H., Sloane, D. M., Clarke, S. P., & Vargas, D. (2004). Nurse burnout and
patient satisfaction. Medical Care, 42(2), 1157-1166. doi: 10.1097/01.mlr.
0000109126.50398.5a
Wagner, J., Liston, B., & Miller, J. (2011). Developing interprofessional communication skills.
Teaching and Learning in Nursing 6, 97-101. doi:10.1016/j.teln.2010.12.003
Wieck, K. L., Dols, J., & Landrum, P. (2010). Retention priorities for the intergenerational nurse
workforce. Nursing Forum, 45(1), 7-17.