50 august 5 :: vol 29 no 49 :: 2015 NURSING STANDARD

Teamwork requires co-operation, co-ordination and communication
between members of a team to achieve desired outcomes. In industries
with a high degree of risk, such as health care, effective teamwork
has been shown to achieve team goals successfully and efficiently,
with fewer errors. This article introduces behaviours that support
communication, co-operation and co-ordination in teams. The central
role of communication in enabling co-operation and co-ordination is
explored. A human factors perspective is used to examine tools to improve
communication and identify barriers to effective team communication in
health care.

Heather Gluyas Associate professor, School of Health Professions,
Murdoch University, Mandurah, Western Australia.
Correspondence to: [email protected]

Communication, co-operation, human factors, patient safety,
revalidation, structured communication tools, team briefing, teamwork

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E�ective communication and
teamwork promotes patient safety
NS805 Gluyas H (2015) Effective communication and teamwork promotes patient safety. Nursing Standard.
29, 49, 50-57. Date of submission: March 15 2015; date of acceptance: May 14 2015.

Aims and intended learning outcomes
This article aims to inform the reader about
effective teamwork and communication. The
behaviours required for effective teamwork,
the key elements of effective communication
and common tools that support successful
communication within a team are discussed.
After reading this article and completing the
time out activities you should be able to:
 Explain the pivotal role of effective

teamwork in promoting patient safety and
quality care.
 Describe the behaviours that are required for

effective teamwork.
 List the barriers to effective communication

in health care.
 Describe common tools that can be used to

improve team communication.
 Relate effective communication to your own

 Develop your communication skills in your

team environment.

Teamwork involves a group of people working
together to achieve a common purpose (St Pierre
et al 2011). Teamwork requires co-operation,
co-ordination and communication between
members of a team to achieve desired
outcomes. In industries where there is high risk,
such as health care, effective teamwork has
been shown to achieve team goals successfully
and efficiently, with fewer errors. Conversely,
poor teamwork has been shown to result in
errors and suboptimal outcomes (Walker 2008,
Donohue and Endacott 2010, Lee et al 2012,
Lyons and Popejoy 2014).

This article introduces behaviours that
support communication, co-operation and
co-ordination in teams, and explores the
central role of communication in enabling

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NURSING STANDARD august 5 :: vol 29 no 49 :: 2015 51

co-operation and co-ordination. A human
factors perspective is used to identify barriers
to effective team communication in health
care and to examine tools that improve
Complete time out activity 1

In health care, teamwork is integral to
providing safe and effective care to patients. The
importance of effective teamwork in response
to the growing complexity of care involving
chronic conditions and associated comorbidities
is increasingly recognised (St Pierre et al 2011).
Most patient encounters involve more than one
healthcare professional and may involve many
people, depending on the type of healthcare
problem. These individuals may include doctors,
nurses, allied health professionals and other
specialist professionals. Teams from different
healthcare sectors, such as primary care, acute
care, mental health or chronic care, may also
be involved. Effective communication – both
verbal and written – between team members and
between different teams is essential to ensure
co-operation and co-ordination of care.

Ineffective communication, which leads to
poor co-operation and co-ordination of care,
is a major cause of errors and adverse events in
patient care (World Health Organization
2009). Communication errors occurring
at handover, either between team members
or between different teams, may lead to
inaccurate diagnosis, incorrect treatment
and/or medication errors (Wong et al 2008).
Poor communication in teams leads to team
members having different perceptions of
situations and of what is required to manage
them (Brady and Goldenhar 2014). Such
differing perceptions of a situation among
team members may be viewed as the lack of a
shared mental model, and this has been shown
to contribute to serious safety events (Gluyas
and Morrison 2013, Brady and Goldenhar
2014). Moreover, a lack of effective team
communication has been shown to contribute
to delayed response to deteriorating patients
(Endacott et al 2007). Patient safety in
surgical interventions may be compromised
if there is poor team communication (Lyons
and Popejoy 2014). This may result in
serious adverse events such as wrong patient,
procedure and/or site; retained instruments;
infections; and unanticipated blood loss
(Treadwell et al 2014).

Thomas et al (2013) examined data from
459 patient safety incidents relating to clinical
handover in acute care settings. They found

that 28.8% of incidents (n=132) involved
transfer of patients without adequate handover,
19.2% of incidents (n=88) involved omissions
of critical information about the patients’
condition and 14.2% of incidents (n=65)
involved omission of critical information in
patients’ care plans.

Poor communication is not limited to
incidents in the acute sector. It may also be a
factor in poor outcomes when transferring
care between sectors, such as from primary
care to the acute sector and back again (Russell
et al 2013). There is a convincing case for
investing time and resources in improving
communication and teamwork in health care
to improve patient safety.
Complete time out activity 2

Teamwork behaviours
Teams are composed of individuals with
different knowledge, skills and attributes,
who all contribute particular characteristics
to team performance. However, for a team
to perform successfully, individuals must
share an understanding of what is required to
achieve the desired goal (Endsley 2012). This
means team members must work individually
to carry out their duties while maintaining
an awareness of the need for the collective
contribution of team members (Gluyas and
Morrison 2013). The skills that contribute to
successful teamwork include team leadership,
mutual support, situation monitoring and
effective communication (Baker et al 2012).
Table 1 indicates the knowledge and
behaviours that are required to demonstrate
these skills.

Communication is necessary in each of the
skills team members require to contribute
to an effective team (Table 1) and may be
considered as the basis for effective teamwork.
It may involve spoken communication,
non-verbal (gestures, facial expression)
and/or written language. It involves one
person initiating a message, along with
receipt of this message by another person or
persons (St Pierre et al 2011). However, the
powerful effect of cognitive processes on the
communication process should be understood
and recognised, since this is central to
promoting effective communication. A human
factors perspective provides a framework for
understanding these effects and considers the

2 Read the case study
in Box 1. Draw a diagram
indicating the different
teams that may have
been involved in Mary’s
care in the community
and in hospital. Identify
specific points where
effective teamwork and
communication were
required between team
members and teams.

1 Before completing
this article, recall a
time when you were
part of a team that did
not work well together.
Write down the factors
and behaviours that
may have contributed
to this. Once you have
completed the article
and reviewed Table 1,
add any factors you
may have omitted from
this list.

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52 august 5 :: vol 29 no 49 :: 2015 NURSING STANDARD

CPD communication

effect of systems, environments, equipment
and processes on human cognitive abilities
and limitations (Catchpole 2013).

Human cognition is a dynamic process
that allows people to perceive, interpret
and make decisions about required actions
(Gluyas and Morrison 2013). The cognitive
load is relatively low when undertaking
well-known tasks in familiar situations. In such
instances, humans are able to carry out tasks
in a somewhat automatic manner with little
conscious thought. However, in unfamiliar or
complex situations, humans must use increased
conscious attention to process what is going

on around them and what actions are required.
Cognitive overload may occur if the situation
is complex, for example where constantly
changing circumstances require intense cognitive
attention to process what is happening (Endsley
2012). Several cognitive processing failures may
then arise, including attentional tunnelling,
confirmation bias, memory failures (slips and
lapses) and inaccurate mental models (Endsley
2012) (Table 2). These limitations in cognitive
processing may be precipitated or exacerbated
by workload pressures, time pressures, stress,
anxiety, fatigue, poor team relationships,
constant interruptions and changing situational
requirements (St Pierre et al 2011).

The cognitive load of the individuals involved
in the communication may affect their processing
of the information. Communication failures
may occur if an individual is in a situation where
there is cognitive overload, for example because
of the volume of data they are trying to process.
Transmission failures may arise from incomplete,
incorrect, ambiguous or unclear messages,
while reception failures may arise because the
message is misinterpreted, disregarded or not
processed and retained in memory (Endsley
2012). Therefore, it is important to recognise the
context of communication and the individual
stresses that might affect the communication
process. The communication process itself is
only one aspect of effective communication;
there are additional barriers that may lead to
communication failures.

Barriers to e�ective communication
General factors that can increase the likelihood
of communication failures in any setting
include differences in gender, culture, ethnicity,
education and styles of communication.
Also, there are contextual and cultural issues
specific to healthcare settings that may affect
communication in healthcare teams.

One major difference between health care
and many other environments is the existence
of a hierarchical system, both among different
health professional groups and among senior
and junior staff in the same professional group
(Nugus et al 2010). This hierarchy results in
an authority gradient; those further down the
hierarchy may be hesitant to challenge those
further up the hierarchy, raise concerns or ask
questions. In a situation where one member
of the team feels there may be a patient safety
issue, or has concerns of some kind, they may
not feel comfortable raising this or discussing their
concerns with the team (Makary et al 2006,
Reid and Bromiley 2012).

Teamwork skills and required behaviours

Skill Required behaviours

Leadership  Communicate awareness and understanding of the
desired outcome.

 Communicate understanding of purpose, team
roles, responsibilities, task requirements and plan.

 Plan and allocate tasks.

Mutual support  Provide feedback to other team members when

 Provide and request assistance when required.
 Trust in other team members and have confidence

in their actions and intentions.

Situation monitoring  Review ongoing team performance.
 Adjust, adapt and reallocate tasks and

responsibilities as required.

Communication  Share information with other team members.
 Communicate clearly using objective language,

correct terminology and structured processes or
tools, where available.

 Acknowledge communication and check for correct
interpretation (closed loop communication).

(Miller et al 2009, Baker et al 2012, Gluyas and Morrison 2013)

Case study 1: Mary

Mary presented to the GP feeling unwell, with pain in her right leg of several
days’ duration. On examination the GP identified that Mary had tenderness
and swelling in her right calf; she denied any falls or other incidents that may
have caused this. Since Mary had recently taken a flight overseas, the GP
suspected a deep vein thrombosis (DVT). The GP ordered an ultrasound scan
and blood test, which were positive for DVT, and Mary was commenced on
oral anticoagulation therapy. Later that day, she presented to the emergency
department with acute shortness of breath and was admitted with a diagnosis
of pulmonary embolus. She was commenced on parenteral anticoagulation
and respiratory support. After several days, Mary improved and was
discharged into the care of the GP for monitoring of ongoing anticoagulation
therapy, and the community nursing service, which would provide home visits
and support during the recovery phase.

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NURSING STANDARD august 5 :: vol 29 no 49 :: 2015 53

An example that illustrates this authority
gradient is provided in Reynard et al (2009).
A child experienced facial burns from a dry
swab that caught fire from the diathermy
machine during maxillofacial surgery. The
surgeon immediately changed his practice
to using wet swabs, but ascertained from
colleagues that they previously changed to this
practice because the risk of using dry swabs
had already been identified. When the surgeon
asked nursing staff why they did not inform
him of this practice, they indicated that he had
discouraged suggestions in the past, so they did
not feel comfortable raising issues about his
surgical practice (Reynard et al 2009).

Other studies confirm that reluctance to
speak up about possible patient risk is an
important factor in communication errors
(Leonard et al 2004, Makary et al 2006,
Mackintosh and Sandall 2010, Carayon 2012,
Lyndon et al 2012, Okuyama et al 2014).
Lyndon et al (2012) reported that 12% of
staff were unlikely to speak up even when
there was high risk; this reluctance was related
to previous rudeness or intimidation from
other staff. Other factors that contribute to
this hesitancy include poor leadership and
relationships in the healthcare team, fear
of the responses of others, and concerns
about appearing incompetent in ambiguous
or complex clinical situations (Okuyama
et al 2014).

Differing communication styles between
doctors and nurses may exacerbate authority
gradients that exist in health care. Doctors are
educated on a scientific basis that emphasises
cure and treatment in the management of
patient care. This results in a communication
style that tends to be succinct, with a focus on
scientific facts. Nurse education is informed
by science but has a holistic focus on caring
linked to treatment and management. Nurses’
communication style differs from that of
doctors in that it tends to be more narrative,
rather than concisely factual (Wachter 2012).
Communication between different professional
groups can lead to misunderstanding and
misinterpretation of the message being
communicated, because different professional
staff have expectations of others that are
not explicitly communicated (Donohue and
Endacott 2010).

Implicit expectations, or those not
explicitly communicated, may also be
described as a ‘hint and hope’ dialogue.
This can result in the sender and receiver
failing to communicate, with the sender

hinting at what is required and the receiver
completely missing their message. One
example of this is the case of Elaine Bromiley,
a patient who died following a failed
intubation for a surgical procedure (Reid
and Bromiley 2012, Bromiley 2014). During
the emergency situation, the medical staff
involved were focused on continuing to try to
intubate; the patient became severely hypoxic,
resulting in her death 13 days later (Walker
2008). The authority gradient discouraged
any direct assertion by the nurses that the
situation was an emergency. When a nurse
brought in the tracheostomy tray (without
being asked) and stated that it was ready, the
implicit message was: ‘I have brought in the
tracheostomy tray because you need to look
at alternative airway access for oxygenation.’
This was not the message received by the
medical staff, who remained focused on the
task of intubating the patient and ignored
the interruption (an example of attentional
tunnelling, Table 2). A second nurse was
also ignored when she stated that she had
contacted the intensive care unit (ICU) for
a bed. The implied message was: ‘I have
contacted ICU because this is an emergency
and I am worried about the patient’s
deteriorating observations.’ However, the
nurse’s comments were not interpreted
in this way. The communication failures
were a result of differing communication
styles, as well as the authority gradient and
the cognitive overload of the medical staff
attempting to manage the situation.

Cognitive processes to manage challenging situations

Cognitive process Description

Attentional tunnelling Focusing cognitive attention on one aspect of a
situation that is proving challenging in terms of
understanding or task completion, while ignoring
other information from the environment or context.

Confirmation bias A tendency to consider only confirming evidence
and to disregard evidence that does not confirm.

Memory failures
(slips and lapses)

Memory failures are associated with automatic
behaviour, where we intend to do something but
our attention is focused elsewhere. We either
forget to carry out an action (lapse), or undertake
steps of an action in the wrong order or leave out
a step entirely (slip).

Inaccurate mental

Erroneous mental models of events and what
decisions or actions are required, resulting from
flawed perception or comprehension of a situation.

(Adapted from Endsley 2012)


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54 august 5 :: vol 29 no 49 :: 2015 NURSING STANDARD

CPD communication

In health care, teams are often not fixed
or established, but have come together for
a specific purpose. They have not had time
to establish roles and responsibilities or to
articulate clearly the apparent objectives of the
team (Wachter 2012). This can lead to different
perceptions or mental models of the situation
and the required outcomes. Shift work, long
hours leading to fatigue, and other common
factors in health care, such as distractions,
interruptions, workload and time pressures,
add to these different perceptions. Therefore,
it is not surprising that poor communication
within teams contributes to errors and poor
patient outcomes. It is imperative to develop
strategies that decrease the likelihood of
communication failures arising from authority
gradients, from differing professional
communication styles and from cognitive
failures such as those listed in Table 2.

Strategies to improve team communication
in health care
Many strategies to improve communication
rely on organisational structures and
processes. These strategies include education
and training programmes that focus on
improving communication in teams and
developing an understanding of barriers to
effective communication, such as authority
gradients and different communication
styles. Such programmes have been shown to
improve teamwork and communication (Stead
et al 2009, Gorman et al 2010, Baker et al 2012,
Bunnell et al 2013). Other organisational
strategies to improve communication include
implementing practices such as checklists
and read-back protocols for different
clinical situations, instigating structured
communication tools and introducing briefing
and debriefing procedures in teams (Lepman
and Hewett 2008, Gorman et al 2010,
Knox and Simpson 2013, Brady et al 2013,
Goldenhar et al 2013, Lyons and Popejoy 2014).
These steps require commitment from the
organisation’s leadership team and provision of
resources. However, healthcare professionals
can still use many of these strategies, even in the
absence of formal organisational support, as is
discussed in this article.

Team brie�ng and debrie�ng The purpose
of team briefing, huddles and debriefing is
to diminish authority gradients and enable
common agreement on the team’s objectives
and intended outcomes (Wachter 2012,
Goldenhar et al 2013). Briefings may take the

form of a pre-procedure or pre-shift pause,
during which team members articulate their
roles and responsibilities and discuss the
intended outcomes. This may identify agreed
protocols that are intended to alert team
members to changing conditions or other
important information (Brady and Goldenhar

Huddles are ongoing team briefings that
occur throughout the period the team is
working together. They involve team members
coming together frequently for short periods
to review and make plans for ongoing care.
If used effectively, this strategy addresses
problems with overload or limited short-term
memory capacity, establishes safeguards in
the process and improves the effectiveness
of communication in the team. The essential
elements of a huddle are that it is short, it has a
team facilitator, discussion is encouraged based
on data and the focus is on problem solving and
solutions planning (Goldenhar et al 2013).

Debriefings involve the team coming together
at the end of a shift or procedure to discuss
what went wrong and what went well (St Pierre
et al 2011). Team performance is improved
through the lessons learned. Debriefings enable
team members to recognise opportunities to
speak up in critical situations, or instances of
communication failure, for example, attentional
tunnelling, confirmation bias, memory failures
and inaccurate mental models. Facilitation
and leadership are essential to ensure a safe,
blame-free environment for debriefing, in which
all team members feel comfortable to discuss
aspects of the team performance explicitly
(Wachter 2012).

Structured communication tools Structured
communication tools address problems that
may arise as a result of authority gradients,
different professional communication styles
and cognitive limitations. These tools establish
safeguards in processes, reduce the steps
and variability in processes and increase the
likelihood of effective communication (Lee
et al 2012). Many different tools have been
developed to provide an objective framework for
structured communication between clinicians in
response to concerns about a patient’s condition
(Gluyas and Morrison 2013). For example, the
SBAR tool, where the mnemonic (Gluyas and
Morrison 2013) indicates:
 Situation: what is going on with the patient?
 Background: what is the clinical background

or context?
 Assessment: what do I think the problem is?

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NURSING STANDARD august 5 :: vol 29 no 49 :: 2015 55

 Recommendation or response: what do I
think should be done in what time frame?

Practice is required to use this form of
communication, to implement it and to
overcome any hesitancy that may occur
because of authority gradients. However,
objective communication focused on data
decreases the likelihood of misunderstanding
and minimises problems with implicit
communication styles (Lee et al 2012). Variants
of the SBAR structured communication tool
have been developed for use in handover of
patient care to other clinicians (Porteous
et al 2009).
Complete time out activity 3

Managing the authority gradient can be
difficult, and the CUS structured tool may
be particularly useful in this situation. The
tool provides a communication process
for escalation, to focus attention when
there are safety concerns that are not being
acknowledged or addressed by other members
of the team (Mackintosh and Sandall 2010).
The CUS tool involves individuals using the
following prompts to communicate:
 I am Concerned.
 I am Uncomfortable.
 This is a Safety issue.
For example, in a situation where a patient is
deteriorating and the nurse has been unable
to get a response for urgent review from a
clinician, the nurse might contact that clinician
again, or a more senior member of staff, and
express their concern using the phrase ‘I am
concerned’, stating the reasons for this. If there
is still no timely response, the nurse could
contact the team leader or a senior clinician
and repeat their concern, using the phrase ‘I
am uncomfortable’. If there is still no response,
the nurse could contact the senior clinician
or management and use the phrase ‘This is a
safety issue’, again expressing their concerns
about the patient’s condition and the lack of
timely response.

The escalation in the CUS tool should be
used only for serious and urgent issues, where
the concern is significant. If the concerns raised
are not addressed adequately, then it may be
necessary to escalate them, bypassing the
person with whom the concerns were initially
raised. By using the objective language of the
CUS tool, the focus remains on patient safety.

It is important to note that organisations
have policies or procedures for escalation
when urgent clinical concerns are not being
addressed. The nurse should comply with

these protocols. The CUS tool is an ideal tool
to guide the communications.
Complete time out activity 4

There are several other structured
communication tools that may be used to hand
over the care of patients to other clinicians.
These include the SHARED communication
tool, where the mnemonic indicates Situation,
History, Assessment, Risks, Expected outcomes
and Documentation (Hatten-Masteron and
Griffiths 2009), and I PASS THE BATON,
where the mnemonic indicates ‘Introduction,
Patient, Assessment, Situation, Safety concerns,
THE Background, Actions, Timing, Ownership
and Next’ (Youngberg 2013).

With the exception of CUS, all these
communication tools can be used for both
verbal and written communication (CUS is
usually used in time-critical situations that
require immediate response). The tools provide
an objective framework for communication
for both the sender and receiver of the message,
decreasing the cognitive load that may lead to
communication failures.

Checklists and read-back protocols Checklists
and read-back protocols can be useful tools
in assisting to prevent communication
breakdowns, since they provide a visual format
for standardised communication (Lyons and
Popejoy 2014, Treadwell et al 2014). They act
as ‘memory joggers’ to decrease the likelihood
of cognitive slips and lapses associated with
automatic tasks. They also provide a prompt

4 Review the
case study in Box 2.
Assume that the SBAR
communication with the
doctor has not elicited
an appropriate response.
Samuel’s respiratory
rate is decreasing further
and he can be roused
only with difficulty. Using
the CUS headings (‘I am
concerned’, ‘I am
uncomfortable’, ‘This is
a safety issue’), write
down how the nurse
could objectively convey
concern about the
patient’s deteriorating

3 Read the case study
in Box 2. Identify the
barriers to effective
demonstrated in this
situation. Using the
SBAR communication
tool – with the headings
‘situation’, ‘background’,
‘assessment’ and
or ‘response’ – write
down how the nurse
could communicate in
an objective way the
clinical information
underlying concern
about the …

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