Quality and Safety in Nursing/Team Development

In nursing, teambuilding is crucial to providing good patient outcomes. Bajnok, Puddester, MacDonald, Archibald, & Kuhl (2012) state “Effectively working together as part of an interprofessional team is now included in the expectations for most healthcare providers.” Baggs & Schmidt state “Empirical evidence shows that collaboration and teamwork lead to improved patient care, reduced healthcare costs, and improved job satisfaction”(as cited in Bajnok et al. , 2012, p. 76). Sollecito and Johnson (2013) discuss the stages of team development. These stages include forming, storming, norming, and performing. The team comes together and develops goals for the team to accomplish. In this stage, members are still learning the “norms” of the team. They usually will not speak up or disagree at this point because they are unsure of the group. As the group progresses the storming phase begins. In some groups there will never be a storming phase. The storming phase is generally classified by members competing for roles in the group. There may also be some disagreement about the goals and processes of the team. As the storming resolves the group usually moves to the norming stage. This is where the group agrees on expectations, goal, processes, and roles. The last stage is the performing stage. This is where the group performs and accomplishes goals. They understand the norms and the roles of each team member. This is the stage where optimal work is being accomplished. Quality and Safety in Nursing/Team Development The topic for this team building chapter is a team huddle. Team huddles are done the first 5-10 minutes of every shift. This is a time for nurses to get together and plan the day. They are informed of what patients are currently on the floor, what is expected to come, what is going good on the two previous shifts and what has gone bad. The nurses are also asked for their input regarding the upcoming shift. Members are also allowed to ask questions and promote ideas to make the shift run smoother.

An article in The Clinical Teacher titled “Teachers: Team huddles: the role of the primary care educator” discusses the importance of team huddles. “The Institute for Healthcare Improvement (USA) has recommended the ‘team huddle’ as one communication strategy to improve health care outcomes” (Fogarty, 2010). Communication is important in keeping a team at optimal performance. It increases satisfaction and patient outcomes. Forgarty suggests that there should be form structured to present the plan for tasks and roles and barriers and facilitators for the day. There are two recommendations for what should be communicated during the huddle. First, patient care issues: direct care, psychosocial, and administrative. Second, systems and staffing issues: staffing needs, and supply and process issues. When staff is aware of all issues at the beginning of the shift the team is more adequately prepared to function is a cohesive manner providing better care to the patients. This also improves employee satisfaction because they are not in constant wonder of what is going on around the nursing unit.

The article titled “Huddles: Improve office efficiency in mere minutes” was published in Family Practice Management in 2007. It provides eight suggestions on how to huddle. 1. Get physician buy in 2. Settle on a time to meet consistently 3. Experiment with different participants 4. Limit huddles to 7 minutes or less 5. Hold the huddle in a central location 6. Have everyone stand the entire time 7. Designate a huddle leader and develop a standard agenda 8. Identify a huddle champion who can provide daily discipline These suggestions are given for family practice residents but can mostly be used throughout the all healthcare huddles.

The team huddles is something that has been established at Intermountain Healthcare. It is used in every area, not just nursing. There is a video that is accessible on youtube titled “Intermountain Healthcare uses daily team huddles to innovate and improve health.” It shows how the central supply unit at Logan Regional Hospital is using team huddles at the beginning of every one of their shifts.

In summary, team huddles are a new idea to healthcare which can significantly improve patient outcomes, employee satisfaction, and efficiency. In the past we have seen many sports teams using huddles to plan their next play so that everyone is “on the same page.” Now healthcare has taken this idea to use so that the whole team is “on the same page.” Everyone has an understanding of what is going on currently on the unit, what is being worked on, and what is expected during the shift. In order to implement a successful team huddle there needs to be a set amount of time (5-10 min), a structured agenda, a team leader, and a set location. The huddle must be consistently performed with interaction from the staff. There are many articles produced on this topic. For information on healthcare huddles search was conducted using the Academic Search Premier (EBSCO) with the search team “team huddles.”


Bajnok I., Puddester D., MacDonald C., Archibald D., & Kuhl D. (2012). Building positive relationships in healthcare: Evaluation of the teams of interprofessional staff interprofessional education program. Contemporary Nurse, 42(1), 76–89.

Fogarty, C., Schultz, S. (2010). Teachers: Team huddles: the role of the primary care educator. The Clinical Teacher, 7(3), 157-160.

Logan Regional. Intermountain Healthcare uses daily team huddles to innovate and improve health. Retrieved March 15, 2013 from

Sollecito, W. A., & Johnson, J. K. (2013) Continuous quality improvement in healthcare. (4th edition). Boston: Jones and Bartlett.

Stewart, E., Johnson, B. (2007). Huddles: Improve office efficiency in mere minutes. Family PracticeManagement, 14(6), 27-29.


Registered nurses often work in stressful and unpredictable environments that require effective teamwork and communication to provide safe and therapeutic patient care. Unfortunately, there is a long-standing phenomenon in nursing culture often described as “nurses eating their young” that creates incredible hardships for nurses trying to succeed in their new occupation (Simons & Mawn, 2010). In fact, a consequence of nurses working in a culture of bullying is job dissatisfaction, which ultimately leads to increased rates of absenteeism, turn-over, as well as decreased productivity, satisfaction, and morale (Cleary, Hunt & Horsfall, 2010). Nurse leaders are well positioned to role model acceptable in nursing behavior, to identify nurse bullying, and to help empower nurses to respond to these challenges through education and skill development (Berry, Gillespie, Gates & Schafer, 2012).

Culture of Nurse Bullying

In recent literature, various terms have been used to describe the intimidation and hostility experienced by nurses in the workplace including; bullying, horizontal violence, and verbal abuse (Simons & Mawn, 2010). While these expressions are used interchangeably and often share behaviors such as sabotage, scapegoating, and excessive criticism, bullying is best described as “a form of aggression that occurs when employees perceive negative actions directed at them from one or several individuals over time; employees have difficulty defending themselves against these actions” (Simons & Mawn, 2010, p. 305).

Recent studies of nurse behavior have discovered that bullying collects around three basic themes; erosion of professional competence and reputation, personal attack, and attack through work roles and tasks (Hutchinson, 2009). Wearing down a nurse’s reputation is often done through the subtle means of gossip and social exclusion which are meant to negatively influence others’ perceptions of the nurse’s ability to do her job (Hutchinson, 2009). Bullying through personal attacks is often more direct and involves “behaviors such as belittling, blaming, and public humiliation” (Hutchinson, 2009, p. 148). Lastly, bullying through work tasks often includes the withholding of important information, needless interruptions and imbalanced work assignments (Hutchinson, 2009). The insidious nature of these behaviors has been so normalized by some that it has been described as “part of the job” and has become an inherent part of the nursing culture (Hutchinson, 2009).

The incidence of workplace bullying “has been increasingly identified and highlighted as a serious problem in healthcare generally, and in other major employment sectors around the world” (Cleary, et. al, 2010, p. 331). In fact, a recent article published by the American Journal of Nursing, reported “as many as 90% of new nurses have experienced some form of coworker incivility” (Major, Abderrahman & Sweeney, 2013, p. 66). Similarly, a study published by the Journal of Nursing Scholarship describes nearly 73% of the 197 new nurses surveyed reported experiencing a workplace bullying event within the previous month (Berry, et. al, 2012). Despite the incredibly compassionate patient care provided by nurses every day, “bullying is considered to be widespread and creates a harmful workplace environment” (Cleary, et. al, 2010, p. 331).

The real implications of such prevalent nurse bullying behaviors cannot be ignored by nurse leaders when “about one third of novice nurses who experience workplace bullying intend to leave their current position” (Berry, et. al, 2012, p. 80). Additionally, when bullying behaviors are modeled by senior nurses to new nurses in the stressful patient care environment, it starts to become an expected occurrence and seen as an acceptable coping strategy cycle that the new nurse will start to perpetuate (Berry, et. al, 2012).

It’s imperative that nurse leaders do not accept nurse workplace bullying. Efforts to consistently communicate a zero tolerance policy are important, but are not enough to counteract a longstanding bullying culture (Berry, et. al, 2012). Providing nurse leaders and staff nurses, both new and seasoned, with effective communication education opportunities will better equip them to respond appropriately in workplace interactions. An example of communication training found to be effective for healthcare professionals is “Crucial Conversations” a strategy developed by Patterson and colleagues that outlines a framework for conversations that are likely to be emotionally charged, have high stakes, or where strong differing opinions exist (Major, et. al, 2013). Interestingly, reports reveal that improvement in how well nurses communicate during difficult conversations can lead to error reduction, lower nursing turn-over rates, and improved quality and productivity (Major, et. al, 2013).

Chapter Summary

The relationship between workplace bullying and decreased work productivity, burnout, and employee retention is unmistakable and is cause for continued concern among nurse leaders because it continues to be so widespread (Berry, et. al, 2012). Establishing and communicating clear expectations of acceptable behavior is essential in developing a positive nursing culture free from the damaging effects of nurse bullying. A strategy to help address bullying is to use the crucial conversation model (Cleary, et. al, 2010). Well trained nurse leaders and staff who possess strong communication skills will be well positioned to lead and support nurses in their challenging caregiver roles.

References Berry, P. A., Gillespie, G. L., Gates, D. & Schafer, J. (2012). Novice nurse productivity following workplace bullying. Journal of Nursing Scholarship, 44(1), 80-87. DOI: 10.1111/j.1547-5069.2011.01436.x

Cleary, M., Hunt, G. & Horsfall, J. (2010). Identifying and addressing bullying in nursing. Issues in Mental Health Nursing, 31, 331-335. DOI: 10.3109/01612840903308531

Hutchinson, M. (2009). Restorative approaches to workplace bullying: Educating nurses towards shared responsibility. Contemporary Nurse, 32(1-2), 147-155.

Major, K., Abderrahman, E. A. & Sweeney, J. I. (2013). Crucial conversations in the workplace: Offering nurses a framework for discussing-and resolving-incidents of lateral violence. American Journal of Nursing, 113(4), 66-70. Retrieved from http://journals.lww.com/ajnonline/Fulltext/2013/04000/_Crucial_Conversations__in_the_Workplace.35.aspx

Simons, S. R. & Mawn, B. (2010). Bullying in the workplace- A qualitative study of newly licensed registered nurses. American Association of Occupational Health Nurses Journal, 58(7), 305-311. DOI: 10.3928/08910162-20100616-02