Framework for Nursing in General Practice
7 Communication and Teamwork
The new GMS contract challenges traditional attitudes and working practices, embracing a whole team approach to improving the quality of care. It will be important for practice teams to work together effectively to identify patient needs, plan work and involve all members in decision making and developments in order to fulfil the requirements of the contract.
The contract states that "when making changes to the working practices of nurses, the practice will be expected to involve them in the decision making process". As their work becomes more specialised, with some services effectively being nurse led, closer involvement of nurses in the planning and delivery of services will be needed. Without such involvement, the ability of nurses to effectively contribute to meeting patient needs and practice goals may be lessened.
Effective teamwork is underpinned by effective two way communication. If the nurse is to play an active role within the team, she/he will need to be well informed, have effective lines of communication within the practice and professional networks which extend beyond it. Increasingly effective communication involves having access to and skills in the use of IT systems. Both practices and NHS Boards have an important role to play in facilitating practice nurse access to IT.
This chapter is based on standards 5.1 and 5.2 relating to communication and teamwork and the availability and use of IT systems to underpin effective communication.
An effective team can be defined as one where:
Roles and relationships are accepted and understood
There is mutual support, openness and trust among members
Task expectations and accomplishments are high with members taking initiative and energy being channelled into effective work.
There is respect for individual differences in values, personalities and skills.
Individuals' needs are met.
Effective teams usually contain a mix of experience and expertise and seldom depend on rank or status. This presents a particular challenge for practices as small organisations, as GPs need to be both the employer, strategic leader and decision maker and a professional peer to practice nurses in their employment. Inevitably it is difficult to separate out these roles, which can lead to nurses feeling excluded as a full member of the team. Practice nurses bring a wide range of clinical, professional and leadership skills to the team, often from an extensive career in nursing. Effective teamwork should aim to ensure that these are made good use of in planning, delivering and evaluating quality patient care.
Whilst all professionals learn to some extent how to work as a team as part of their training, it should never be assumed that simply putting a disparate group of professionals together will produce an effective team.
For a team to function effectively:
The team needs to have a reason for working together.
Members need to be interdependent i.e. they need each others expertise.
Members need to be committed to the idea that working together as a team leads to more effective decisions than working in isolation.
The team needs to be accountable as a functioning unit.
Building and maintaining relationships with other colleagues and understanding the different needs of others are key factors to building an effective practice team. This will involve being open to different viewpoints and valuing the contribution that others can make.
Three key factors are common to effective teamwork and essential to making an effective practice nursing contribution:
Identification of roles
To build teams and to work in them, there needs to be clarity of what is expected of team members. Whatever roles individuals have within the practice team, others will have certain expectations. These expectations relate to how the role is perceived and the assumptions made about that role. Tension and conflict can arise if others are unclear about an individual's role or if they cannot make clear distinctions between roles and responsibilities of others.
Effective and efficient processes
Processes include making effective use of electronic communication, ensuring that time is made for team members to communicate formally and informally and making effective use of formal meetings and team based learning events. Because it is often assumed that teams will work simply because we put people together, little thought is often given to making sure that the processes actually are in place and work effectively.
Maintaining a high level of morale
In general, people prefer the greatest involvement in decisions that are closest to them and affect day-to-day work. Participative decision making promotes a sense of ownership and leads to greater commitment in implementation. It also frequently produces decisions that are technically better: a group tends to have a greater collective knowledge and expertise than an individual.
Delivering effective clinical services that meet the health needs of the practice population is the core purpose of the primary care team. Underpinning this must be effective communication between all members of the team. The NMC Code of Professional Conduct promotes the importance of teamwork stating:
All nurses are expected to work co-operatively within teams and to respect the skills, expertise and contributions of colleagues.
Colleagues must be treated fairly and without discrimination.
Nurses should communicate effectively and share knowledge, skill and expertise with other members of the team as required for the benefit of patients and clients.
The health care record is an important tool to support effective communication. The NMC states that: "all nurses must ensure that the health care record for the patient is an accurate account of treatment, care planning and delivery". The record should provide clear evidence of the care planned, the decisions made, the care delivered and the information shared within the team. The NMC guidelines on records and record keeping http://www.nmc-uk.org/nmc/main/publications/guidelinesForRecordskeep.pdf set out appropriate professional standards for clinical record keeping, which nurses should aspire to.
However, effective clinical communication should go beyond good quality record keeping. It is important for team members to have the time and opportunity to discuss issues and concerns arising from their contact with patients. This may be in a structured way through case reviews, clinical audit or reviewing incidents or complaints or more informal discussions. However it is important that nurses have the opportunity to participate fully in such discussions with clinical colleagues. Discussions with peers either within the practice or through clinical supervision (see chapter 6) can also be helpful in promoting reflection and improving the quality of services.
Involving practice nurses in team decision making
Practice nurses have much that they could contribute to the decision making processes of the practice. Whilst there are clearly issues which will rightly remain the remit of the practice partnership, there are a number of potential benefits to both practices and nurses of being more involved in the clinical leadership of the practice. These include:
Ensuring nursing contributions are effectively targeted on practice priorities. Understanding the practice's clinical priorities will help ensure that the nurses' efforts are appropriately focused.
Job satisfaction. Nurses who better understand their contribution to the overall picture are more likely to feel valued in their job and therefore make a more effective contribution.
Bringing a different dimension to discussions. Different professional disciplines are likely to have different perspectives on the same issue. Ensuring effective involvement of practice nurses can help support innovative solutions to problems.
Nurse led service planning and delivery. Practice nurses are developing discrete areas of expertise, for example in chronic disease management. They may in future increasingly take the clinical lead in some of these areas on behalf of the practice.
Of course there are many different levels of involvement in the business of the practice. For some practices the concept of nurse partnership takes the issue of nurse involvement to its logical conclusion. For others this will not be the right solution. However as a minimum, it is good employment practice to ensure that nurses are well informed about any decisions that will affect their work and have some opportunity to influence the decision making process.
There was a good deal of discussion in local and national workshops about practice nurse involvement in team meetings. Despite the important and growing role of practice nurses within the team their involvement and contribution to meetings was highly variable. Team meetings can be a useful means to support the development and cohesion of the team. However, they need to a have a clear purpose and all members of the team need to feel able to make a contribution. Meeting regularly as a team can help to ensure that all members of the team are clear about work objectives and priorities. Meetings with both the practice team and the wider primary health care team have an important role and practice nurses should be encouraged to participate. Effective communication with other nursing members of the primary health care team is important to ensure coherent patient care and make best use of the skill of team members.
Often practice meetings are conducted out-with normal working hours in order to minimise disruption to services. Both practices and nurses will need to be flexible and sensitive one another's needs in order to be fully engaged.
External networks and communication
Work on the framework has highlighted the lack of effective communication networks between practice nurses and the wider health community in many areas. Some nurses expressed concerns that the Board or LHCC did not know how to actively engage them in local work and in some cases practice nurses were actively discouraged from participation in such communication. The value of effective networking lies in being able to share good practice, develop more consistent approaches to clinical and organisational protocols and seek support from peers. Some LHCCs have been a beneficial, integrating influence for practice nurses, providing a forum for discussion and sharing ideas, as well as providing valued professional leadership. Community Health Partnerships will have in important role in supporting and developing effective communication networks with practice nurses, however, this can only work if practices support and value the involvement of the CHP.
Making effective use of Information Technology
Information Technology is now an increasingly important feature of most work environments. In general practice, the trend towards paper light or paperless record systems and the need to ensure accurate and timely recording of key clinical data to underpin the new GMS contract are driving the move towards increasingly intensive and extensive use of IT systems. Practice nurses, as with other members of the practice team make significant use of practice IT systems.
Clinical record keeping & data gathering
Using IT as part of each clinical contact is increasingly becoming the norm for primary care professionals. This can be in viewing the patient record to date, adding details of the consultation or in using the computer as a means to communicate messages to the patient, for example using on line sources of patient information. For nurses to do this effectively they need full access to a computer during each clinical contact. They also need to have the skills and confidence to use it as a tool to support their practice rather than purely recording data at a later date. Evidence suggests that information recorded during the contact is more likely to be accurate and reliable than data recorded at a later date. However for many professionals, nurses included, this requires a cultural shift in how they practice. It also requires adequate time during each contact to allow for recording of any necessary information.
Education to support effective use of IT
If nurses are to make the most effective use of IT to support their practice and to gather accurate and timely clinical data, it is important that they have access to appropriate IT training and have ongoing support with any queries or problems that arise. Practices and the IM&T departments of NHS Boards have a role in facilitating this, which is ultimately of benefit to all parties in terms of good quality information and more effective patient care.
Using IT to support practice nurse development
There is an increasingly wide range of on line education and resources that can be used by practice nurses to underpin their practice. For most practices, where releasing staff can be extremely difficult, making effective use of on line materials can be an extremely cost effective way of supporting practice nurse CPD. Annex C gives a range of good quality web resources that may be of use to practice nurses. However, many practice nurses reported that access to IT outside of clinical sessions was problematic. There are a number of reasons for this, including constraints of physical accommodation, availability of computers or the hours of the practice nurse. Whilst it is recognised that these constraints are not always easily overcome, the benefits of finding solutions in terms of improved services and supporting practice nurse CPD may be significant.
Improving practice nurse access to IT
Most practices recognise the value of practice nurse access to IT systems. This has been brought more sharply into focus with the need to gather accurate clinical data to meet the requirements of the new GMS contract. However, in many instances this will require additional investment in computer hardware, which is the responsibility of NHS Boards under the new GMS contract.
In developing business cases for new IT hardware, practices should ensure that the needs of practice nurses are clearly articulated as part of the core provision. Equally, NHS Boards will need to ensure that practice nursing needs are taken full account of in making decisions about the provision of resources to practices.