Effective Communication Team

EFFECTIVE TEAM COMMUNICATION IN A
COLLABORATIVE PRACTICENURSING ENVIRONMENT
By
SHARON STAPLETON
BSN, Ryerson University, 1990
A thesis submitted in partial fulfillment of
the requirements for the degree of
MASTER OF ARTS
In
LEADERSHIP
We accept this thesis as conforming
to the required standard
Laurie Leith, MA, Project Sponsor
Pamela Aikman, MALT, Faculty Supervisor
Stan Amaladas, PhD, Committee Chair
ROYAL ROADS UNIVERSITY
July 2009
© 2009 Sharon Stapleton

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Effective Team Communication ii
ABSTRACT
This action research study explored the current state of communication between
nursing team members (registered nurses, licensed practical nurses, and patient
care aides) in a collaborative practice team environment on an Acute Care for
Elders (ACE) unit, identified factors that contributed to and inhibited effective
communication, and suggested strategies leaders could use to facilitate effective
communication practices. Qualitative and quantitative research methods,
including surveys and focus groups, were used to gather data from nursing team
members. Workload, trust, and respect were key factors identified as affecting
effective communication between nursing team members. Recommendations
included establishing effective communication as a priority for the ACE program,
incorporating communication courses as part of any major change initiative
implemented in the ACE program, and creating a culture of trust and respect in
the program between nursing team members.

Effective Team Communication iii
ACKNOWLEDGEMENTS
I would like to acknowledge and express my sincere appreciation to Vancouver
Coastal Health Authority for providing me with this opportunity of leadership education.
I would also like to thank my research participants, who, by offering their time,
knowledge, and experience, assisted me in completing my research project.
To Pamela Aikman, my faculty supervisor, and Laurie Leith, my organizational
sponsor, thank you for your support, guidance, encouragement, and mentorship.
And my family—I could not have done this without your help and support. To my
husband, who encouraged and supported me at every step of the way; my daughter, who
was my "study buddy"; my parents and siblings, who were always there to listen; my
aunt and uncle, who provided me with a sanctuary while at residencies; and my
grandmother, who showed me that learning is a wonderful, lifelong process—I could not
have completed this journey without you.

Effective Team Communication iv
TABLE OF CONTENTS
ACKNOWLEDGEMENTS iii
TABLE OF CONTENTS iv
LIST OF FIGURES vii
LIST OF TABLES vii
CHAPTER 1: FOCUS AND FRAMING 1
The Opportunity 2
Significance of the Opportunity 4
Systems Analysis of the Opportunity 6
Organizational Context 8
Conclusion 11
CHAPTER 2: REVIEW OF THE LITERATURE 12
Collaborative Practice 12
Definition of Collaborative Practice 12
Collaborative Practice and Patient Care 13
Summary 14
Communication 15
Definition of Communication 15
Communication and Patient Care 15
Communication and Leadership 17
Summary 19
Trust 19
Definition of Trust 20
Trust and Collaboration 20
Trust, Leadership, and Change 21
Summary 22
Conclusion 22
CHAPTER 3: RESEARCH APPROACH AND METHODOLOGY 23
Research Approach 23
Project Participants 25
Research Methods 26
Survey 26
Focus Groups 28
Validity and Reliability of Data 30
Study Conduct 31
Data Analysis 32
Trustworthiness 33
Ethical Issues 34
Respect for Human Dignity 35
Respect for Free and Informed Consent 35
Respect for Vulnerable Persons 36
Respect for Privacy and Confidentiality 36
Respect for Justice and Inclusiveness 37
Balancing Harm and Benefits 37
Minimizing Harm 37
Effective Team Communication v
Maximizing Benefits 38
Conclusion 38
CHAPTER 4: ACTION RESEARCH PROJECT RESULTS AND CONCLUSIONS ... 39
Study Findings 39
Survey Findings 39
Focus Group Findings 42
Focus Group A 42
Focus Group B 46
Study Conclusions 50
Respect 51
Trust 52
Increased Workload 53
Communication Skills 53
Ongoing Educational Courses 54
Scope and Limitations of the Research 55
Participants 55
Number of Focus Groups Held 55
Researcher 56
Conclusion 56
CHAPTER 5: RESEARCH IMPLICATIONS 57
Recommendations 57
Recommendation 1: Establish Effective Communication Between Nursing Team
Members as a Priority for the ACE Program 57
Recommendation 2: Make Education on Effective Communication a Part of all Major
Change Initiatives Implemented Within the ACE Program 59
Recommendation 3: Establish a Culture of Trust and Respect Between Nursing Team
Members on the ACE Units 61
Recommendation 4: Assess the Possibility of VGH Creating a Communication
Workshop Specifically for Nursing Staff Who Want to Become Nursing Leaders on the
ACE Unit 62
Organizational Implications 63
Implications for Future Research 65
Measurable Impact of Effective Communication on CP 66
Measurable Impact of Culture on CP 66
Conclusion 67
CHAPTER 6: LESSONS LEARNED 68
Lessons Learned From the Research Process 68
Personal Lessons Learned 69
REFERENCES 71
Appendix A: Letter of Invitation to Participate in Survey 77
Appendix B: Informed Consent and Confidentiality Form for Survey 79
Appendix C: Survey Questions 80
Appendix D: Focus Group Questions 82
Appendix E: Letter of Invitation for Focus Group 83
Appendix F: Informed Consent and Confidentiality Form for Focus Group 86
Appendix G: Confidentiality Agreement 89
Effective Team Communication vi
Appendix H: Survey Responses by Nursing Discipline 90

Effective Team Communication vii
LIST OF FIGURES
Figure 1. Respondents' number of years of work experience 40
LIST OF TABLES
Table 1. Responses to Survey Questions 41

Table HI. Survey Responses by Nursing Discipline 90
Effective Team Communication 1
CHAPTER 1: FOCUS AND FRAMING
Today's health care environment is challenging, fast paced, and demanding.
There is currently tremendous pressure to make changes in the health care system to
control costs while at the same time contend with both the growing needs of patients and
forecasted staff shortages. The impact of these pressures on frontline staff provides health
care leaders with many opportunities to use and grow their leadership skills, as frontline
staff look to their leaders to help navigate them through the change. People first follow
the person, then the plan (Kouzes & Posner, 2002).
Through having worked in the health care system in various roles for over 20
years, I have been involved in numerous projects and experienced firsthand the impact of
many changes. As acting director of operations, medicine at Vancouver General Hospital
(VGH), a hospital under the Vancouver Coastal Health (VCH) umbrella, one of my
responsibilities is assessing and implementing strategies to help mitigate current and
future staffing shortages. My portfolio includes the Acute Care for Elders (ACE)
program. In 2007, in the ACE program there was a vacancy rate for registered nurses
(RN) of 8.9%, which translated into approximately seven full-time staff members. VCH
(2007) has forecast a 39% shortfall of RNs by 2015.
One organizational initiative implemented at VGH and designed to help reduce
the impact of the RN shortage is collaborative practice (CP). Under this initiative, VGH
hired licensed practical nurses (LPNs) and patient care aides (PCAs) into vacant RN
positions (positions that have not been filled RNs, despite recruitment drives locally,
nationally, and internationally). RNs, LPNs, and PCAs then have been working together
in collaborative teams to provide patient care. Due to the existing vacancy rate for RNs,
the ACE program was targeted as one of the first areas at VGH to implement CP.
Although much research has focused on nurse-physician communication,
effective nursing team communication is a vital aspect of a positive nursing practice
environment (Apker, Propp, Ford, & Hofmeister, 2006). One of the indicators of a high-
functioning nursing team is quality patient care, and "clear, mutually understandable
communication is necessary for good patient outcomes" (Milligan, Gilroy, Katz, Rodan,
& Subramanian, 1999, p. 47). With this in mind, the question I researched was the
following: How can leaders facilitate effective communication between nursing staff
(RNs, LPNs, and PCAs) on an ACE unit and a collaborative team practice environment?
I also explored these subquestions:
1. What is the current state of team communication on the unit?
2. What communication skills are needed for effective collaborative team
communication?
3. What factors contribute to the current state of team communication on the unit?
As a leader, I was keen to be involved in a research endeavour that would,
through the engagement of staff and key stakeholders, facilitate the learning of new
knowledge, contribute to the professional growth of staff, and positively impact the
implementation of a project.
The Opportunity
The model of care practised prior to the implementation of CP in the ACE units at
VGH was primary nursing. Primary nursing is based on the philosophy that a single
primary nurse is responsible and accountable for the care of an individual patient. As the
primary nurse is typically very knowledgeable about the patient, this model of care is
associated with a high level of clinical autonomy for the nurse. Primary nursing is often
associated with the belief that the RN must be the exclusive provider of patient care
(Ritter-Teitel, 2002). Under the primary nursing model of care, each RN on the ACE
units at VGH had a patient assignment that he or she was responsible for. The RNs
discussed their patient assignment at daily nurse-led rounds, interacted directly with the
physicians and other health team members about their patients, and were the main point
of contact for the families of the patients. PC As worked under the supervision of the
RNs.
In staff meetings that I organized with the ACE RNs to explain the process and
timeline of this initiative and that were attended by the ACE frontline leadership team
and representatives from Professional Practice and Human Resources, the ACE RNs
stated that they preferred the individual responsibility and accountability of having their
own assignment (i.e., primary nursing) to working in a collaborative team (i.e., CP).
While acknowledging the current and future RN staffing deficits and the negative impact
of these staffing deficits (e.g., high overtime, increased workload, increased stress and
burnout), ACE RNs expressed concerns regarding the implementation of CP. Their
concerns included clarity of roles and responsibilities for each team member (RN, LPN,
PCA), continuity of patient care (e.g., Are too many nursing staff looking after one
patient?), and quality of patient care provided (e.g., Are LPNs and PCAs able to provide
the level of care that is required on the units?). After listening to their concerns, I
recognized that one common thread among all the issues raised was communication; the
RNs perceived a lack of communication from leadership about the details of CP (i.e.,
how it specifically would affect them in their day-to-day work on the unit) and were
unsure about how they were going to communicate with the new team members (LPNs
and PCAs) regarding patient care, because the new team members were not RNs.
According to Ritter-Teitel (2002), the most intensive communication is between
team members. Clark (2008) stated that communication is the "exchange and flow of
information and ideas from one person to another . . . and is the chain of understanding
that integrates the members of an organization from the top to bottom, bottom to top, and
side to side." flf 3). My hope was that by engaging the nursing staff in this research
project, they would gain the knowledge and tools necessary to facilitate their transition
from an individual, autonomous working environment to an effective, high-functioning,
collaborative team environment, where the provision of quality patient care remains a
priority.
Significance of the Opportunity
CP was implemented in the ACE unit in September 2008. The new staff mix was
RN (50%), LPN (17%), and PCA (33%). CP uses a mix of care providers, who work
together to provide total care to an assigned group of patients. It is based on the belief
that when patient care activities and efforts of a diverse team of caregivers are
coordinated by an RN, the team's total effort will surpass what can be done individually
(Ritter-Teitel, 2002). VGH sees CP as a key pillar to support patient flow, care, and
capacity management and to align resources based on the needs of the patients. VGH
feels that CP will improve the ability to provide safe care by mitigating the existing
human resource gap (overtime is currently used to fill vacancies, unanticipated absences,
and rapid fluctuations in census) and maximizing the RN, LPN, and PCA scope of
practice (Vancouver Coastal Health [VCH], 2007).
By choosing to conduct this research project as an action research study, I had the
opportunity to use a process that is "based on collaborative problem solving . . . between
researcher and client which aims at both solving a problem and generating new
knowledge" (Coghlan & Brannick, 2007, p. 9). This research approach aligns with two of
the underlying principles of CP: teamwork and collaboration. Action research also
involves change, and in turn this intended change involves re-education. Re-education,
according to Coghlan and Brannick, "refers to changing patterns of thinking and action
that are currently well established in individuals and groups . . ..and depends on
participation by clients in diagnosis, fact finding and free choice to engage in new kinds
of action" (2007, p. 10). As previously identified, one of the challenges of implementing
CP was that the model of nursing care, which was well established on the ACE units,
needed to be changed. Through enacting action research, and with the participation and
engagement of key stakeholders, my expectation was that I would facilitate both problem
solving and re-education.
The major stakeholders of my action research project at VCH were the nursing
staff, patients and their families, and the organization itself. The benefits of undertaking
the action research project included for the nursing staff understanding and knowledge of
the principles of effective communication and potential strategies to increase effective
communication on the ACE units; for patients and families the provision of seamless,
quality care by a knowledgeable, high-functioning team; and for VCH increased staff
retention, staff productivity, staff morale, and patient satisfaction and decreased overtime,
sick time, and job vacancies.
Systems Analysis of the Opportunity
If the existing workforce patterns for RNs continue, Canada can expect to
experience a shortage of 78,000 RNs by 2011 and 113,000 RNs by 2016 (Canadian
Nurses Association, 2009). In 2006, 8,300 RNs graduated; it is estimated that 12,000
were needed (Canadian Nurses Association & Canadian Association of Schools of
Nursing, 2008). Due to the increasing average age of RNs (44.8 years in 2006 compared
to 44.5 years in 2003), at any given time approximately 20% of the workforce, or 50,000
RNs, are eligible to retire (Canadian Institute for Health Information, 2008). A policy
brief issued by the Canadian Nurses Association (2007) recognized that optimizing the
work of professional staff, for example through CP, was one strategy to combat this
forecasted shortage; matching the skill level of health care workers with job requirements
could increase the quality and quantity of services provided.
British Columbia's Ministry of Health has also recognized the increasing shortage
of registered nurses and the opportunity that collaborative nursing practice presents.
Through its Nursing Directorate, a department created in 2001 to address nursing
priorities such as the nursing shortage, over $174 million has been spent to date on
programs to recruit, retain, and educate RNs and LPNs. Specific programs that have been
funded related to CP include Clinical Resource for Introducing New LPN Competencies,
a project that developed a decision guide for the appropriate use of LPNs, and Preparing
RNs and LPNs for Collaborative Practice: A Review of Current Educational Activities in
BC, a joint project with the British Columbia Nurses' Union that surveyed and assessed
the educational activities that support the CP of nurses (Province of British Columbia,
Ministry of Health, 2008).
There are two provincial licensing bodies for nurses in British Columbia; The
College of Registered Nurses of British Columbia and the College of Licensed Practical
Nurses of British Columbia. To demonstrate their support of CP, these colleges have
entered into a partnership in the creation of a document outlining practice expectations
for CP between RNs and LPNs. They also offer a joint education session on CP,
reviewing the scope of practice for RNs and LPNs, so that RNs and LPNs understand
their complementary yet differing roles (College of Registered Nurses of British
Columbia, 2005).
The British Columbia Nurses' Union, the provincial union to which all RNs
belong, is supportive of CP. It recognizes the impact that the current and forecasted
nursing shortage has on its members, such as increased requests for overtime and
increased workload, which lead to RNs experiencing increased sick time, injury, stress,
and burnout (Canadian Health Services Research Foundation, 2006). The Hospital
Employees' Union, to which the LPNs belong, also supports CP, as it is seen as an
opportunity for LPNs to be used to the full extent of their scope of practice. The British
Columbia Nurses' Union, College of Licensed Practical Nurses, Hospital Employees'
Union, and the Registered Nurses Association of BC (2003) jointly issued a document to
the chief executive officers of the British Columbia Health Authorities in 2003 titled
"Process in Change for Practice Roles," which outlined the steps requisite to safely
implement CP.
The main focus for these groups, however, has been an endorsement of the
concept of CP. Schober and MacKay (2004), members of the International Council of
Nurses who studied issues related to the implementation of CP, defined effective
communication as a key characteristic essential for the success of CP. They found that
when health care providers developed specific competence in communication, then
problem solving, relationships, and role negotiation were facilitated. With strong
communication skills, individual team members could better understand the expectations
of others and foster mutual trust.
Organizational Context
VCH (2007) serves approximately 25% of British Columbia's population. It has
over 22,000 employees and receives $2.4 billion in annual funding, which is used to run
13 hospitals and 3 diagnostic and treatment centres. Over 308,000 people visit the
emergency department annually, and there are 9,000 in-patient beds in the service region,
providing over 2.9 million patient days of care annually.
VCH's (2007) vision is of being "committed to supporting healthy lives in healthy
communities with our partners through care, education and research" (p. 12). Derived
from this vision are the organizational values of service, integrity, and sustainability.
These values are embedded throughout organizational goals, policies, and programs.
VCH (2007) is guided by five organization goals, one being to "strengthen staff
and physician resources through investments in training, working conditions, and
productivity tools" (p. 23). In its 2007/08 Service Plan, VCH predicted a 39% RN
shortage by 2015 due to a combination of increased population demand and the aging and
retiring workforce. VCH currently employs 3,999 RNs and predicts that in 2015 it will
need 5,214 RNs but only be able to hire 3,251 RNs. VCH has acknowledged that in order
to meet current and future health care needs, fundamental reforms need to be made.
The Vancouver Acute Care Management Improvement Initiative was introduced
by the president and chief executive officer of VCH in January 2006 to review the way
care is managed at VCH and assess for operational improvements. One of the working
groups created under this initiative, comprised of nurse and physician leaders, was tasked
with looking at ways to reorganize how care is provided to improve patient outcomes and
make health service delivery more efficient. CP was one of the reforms identified by this
working group as a way to optimize the scopes of practice of health care professionals,
thereby reducing the impact of the nursing shortage while maintaining and/or improving
patient outcomes and adhering to best practice standards. CP looks at how to deliver care
collectively, and in partnership with, all providers. It maximizes the practice of each
health care discipline in order to provide the best standard of care (VCH, 2007). This
organizational initiative aligns with the Ministry of Health value of efficiency (providing
quality, effective evidence-based services is a cost-effective way) (Province of British
Columbia, Ministry of Health, 2005).
The ACE units were one the first medicine programs at VGH to implement CP
under the Vancouver Acute Care Management Improvement Initiative. The ACE
program was created in 2001 to provide specialized, interdisciplinary patient-centered
care to adults over age 70 with an acute medical illness and actual or potential functional
decline. The program uses a variety of approaches to address the functional, cognitive,
and health care needs of older adults with a variety of geriatric issues such as falls,
dementia, and caregiver stress. Nursing care for older patients with acute medical
problems and/or geriatric issues is complex and requires skill and knowledge in the early
identification and management of risk, evaluation of response to medical problems,
intervention in geriatric issues, and prevention of iatrogenesis or complications (Shaw,
2007).
In September 2008, when CP was implemented, there was a vacancy rate of 8.9%
for RNs. Over the previous year, through the Employee Engagement department at VGH,
programs such as the Employed Student Nurse program, the New Graduate RN program,
and the Internationally Educated Nurse program had been used to recruit nurses. Despite
these efforts, the ACE RN vacancy rate has remained at 8.9%. A combination of the
increased demand on the program and the existing RN vacancies means that the ACE
program has a current RN overtime rate of 8.7%. In the 2008/2009 budget for the ACE
program, the target RN overtime rate was 5% (VCH, 2008).
To determine if CP was appropriate for the ACE program, patient acuity levels
were assessed, using a rating scale developed by the CP working group, in the ACE units
for a period of 2 weeks in November 2007. This assessment helped determine if there
were patient care tasks that were within the scope of practice and therefore suitable to be
assigned to an RN, LPN, or PCA. Overtime rates, vacancy rates, and sick time rates for
RNs were also looked at. The CP working group, in looking at the collected data,
confirmed that it was appropriate to implement CP in the ACE units.
The goals of CP, as defined by VCH, are to improve the ability to provide safe
patient care by mitigating the human resource gap—overtime is currently used to fill
vacancies and unanticipated absences and deal with unexpectedly high numbers of
patient admissions—and maximize the use of available health care professionals' scope
of practice. CP will facilitate getting the right health care professionals providing the
right care, to the right patient, at the right time (Vancouver General Hospital Patient Care
Services Team, 2007).
The College of Registered Nurses of British Columbia (2008) and the College of
Licensed Practical Nurses of British Columbia (2004), in their standards of practice, have
a code of ethics for their practitioners. Both colleges reference the value of providing
safe, compassionate, competent, and ethical care to their patients. CP, defined by VCH as
a cooperative venture with the goal of providing quality nursing care, aligns with these
codes of ethics as CP has at its core the goals of patient-centered care, effective
communication, and shared decision making, promotes a climate of mutual understanding
and acceptance of each other's roles and respect for the shared and unique competencies
of each member of the discipline of nursing (Vancouver General Hospital Patient Care
Services Team, 2007).
Conclusion
Schober and MacKay (2004) identified four factors required to create a CP
environment: communication, participation, consensus, and shared leadership.
Communication touches many aspect of the CP process. There is communication
between nurses, communication between nurses and other interdisciplinary team
members, communication between nurses and patients and families, and communication
between staff and the organization. Communication is essential to the success of CP.
The following chapter provides an overview of current literature and identifies
key terms and concepts related to the focus of this research project.
CHAPTER 2: REVIEW OF THE LITERATURE
Chapter Two will provide definitions of key terms and an exploration of key
concepts as they relate to the focus of this project. This research study explores how
leaders can facilitate effective communication in a collaborative practice nursing
environment. Determining what can be done to facilitate effective communication
requires a thorough review of the literature related to collaborative practice,
communication and trust.
Collaborative Practice
"No man is an island entire of himself; every man is a piece of the continent, a
part of the main" (Donne, 2009, ^ 2). When John Donne composed this 500 years ago, he
was not thinking about how health care would be practised centuries later. Due to the
constant and rapid change in health care as a result of financial restraints, human resource
shortages, and technological advancements, one of the primary goals of health care today
is to provide quality patient care with fewer resources. CP is one such intervention
designed to help meet this goal.
Definition of Collaborative Practice
VCH is implementing CP to help mitigate the effects of the nursing shortage. The
definition of CP remains highly variable, ranging from "cooperation" to "joint venture"
to "compromise" to "shared responsibility" (Henneman, Lee, & Cohen, 1995). For the
purposes of this research study, I defined CP as RNs, LPNs and PC As working together
in a team environment to provide patient care. Each of these three divisions of nursing
staff has different education programs and different regulations to meet in order to be
licensed to provide patient care. From a systems theory perspective, the concept that the
whole is more than the sum of the parts defines the value of CP. Systems thinking
focuses on the individuals in a system and how these individuals influence one another.
Bowen's (1978, as cited in Akhavain, Amaral, Murphy, & Uehlinger, 1999) family
systems theory stated that how a person functions in the work system affects the
functioning of the other people in that system. Collaboration, from this perspective, is
based on the following assumptions: All individuals are interdependent and dependent on
the system, all individuals are connected to the same goal, each individual's contribution
is of equal value and equal importance, and each contribution affects the outcome. It is
important to understand CP from a systems theory perspective, because one of the beliefs
of CP is that by working together as a team and maximizing the scope of practice of each
RN, LPN, and PC A, the efforts of the team will surpass what can be done individually
(Ritter-Teitel, 2002).
Collaborative Practice and Patient Care
Nurses are the backbone of the health care system; health care providers rely on
licensed nurses (RNs and LPNs) to provide the majority of direct patient care 24 hours a
day, 7 days a week. The current and projected long-term RN shortage has prompted
interest in using RNs with LPNs and PCAs in a CP model to help provide this much-
needed patient care (Crosson & Ferguson, 2005; Spetz, Dyer, Chapman, & Seago, 2006).
Observational studies by Blegen and Vaughn (1998) and Needleman, Buerhas,
Mattke, Stewart, and Zelevinsky (2002a, 2002b) performed in acute and long-term care
facilities provide evidence that there is a positive correlation between nurse staffing
(RNs, LPNs, and PCAs) and patient outcomes. These two studies explored the
correlations between type of nurse staff (RNs, LPNs, and PCAs), patient deaths, and rates
of adverse patient outcomes (including pressure ulcers, falls, and nosocomial infections).
Both studies found evidence that richer nurse staffing is associated with better patient
outcomes. Richer nurse staffing was defined as the RNs and LPNs who have a regulated
scope of practice, as opposed to the PC As who have an unregulated scope of practice.
According to McKenna (1995), quality of care is directly associated with the skill
mix of the nursing staff. He found that the appropriate use of the skill mix of nursing staff
resulted in reduced mortality rates, lengths of stay, costs, and complications and
increased recovery rates, patient satisfaction, quality of life, and patient knowledge and
compliance.
In one large-scale study by Needleman et al. (2002a), researchers examined the
three categories of care provider (RNs, LPNs and PCAs) by measuring the proportion of
nursing hours provided and the number of hours per patient day provided by each
category of staff. The study found that RN staffing had the biggest impact on adverse
outcomes and that lower levels of staffing were associated with higher rates of
pneumonia, urinary tract infections, upper gastrointestinal bleeding, shock, failure to
rescue, and longer lengths of stay. The study found no relation between patient outcomes
and the use of LPNs or PCAs.
Summary
Given the increasing complexity of patient care, the proper use of nursing staff is
a significant challenge for health care providers. Patient safety, decreased lengths of stay,
rising health care costs, a lack of funding, and a shortage of nurses also contribute to this
complicated issue (Buerhaus & Needleman, 2000). Despite recent studies concerning
patient outcomes and staff mix, there is a lack of literature related to nursing staff mixes
specific to an ACE unit. Additionally, the actual process or evaluation of nursing staff
mix decision making has not been thoroughly investigated. The literature suggested,
however, that determining the right mix of care providers for a patient population is
essential to ensuring best patient outcomes (Cho, Ketefian, Barkauskas, & Smith, 2003;
Needleman et al., 2002a). This same principle can be applied to the CP environment in
the ACE unit at VGH.
Communication
Communication is a key aspect of a well-functioning team and a vital aspect of a
positive nursing practice environment. It was important that I review the current
communication strategies being used by teams and the role of the leader in this
communication, in order to understand how communication is facilitated by the leader in
a team environment.
Definition of Communication
Communication is the exchange and flow of ideas and information from one
person to another; effective communication occurs only if the receiver understands the
exact idea or information that the transmitter intended to send. To communicate
effectively, you must understand what your message is, what audience you are sending it
to, and how it will be perceived. You must also consider the circumstances surrounding
your communications, such as situational and cultural context (Clark, 2008).
Communication and Patient Care
The health care system today requires that nurses communicate with a myriad of
interdisciplinary team members. A true interdisciplinary practice is one where "each
voice is given equal respect" (Rogers, 2004, p. 239), making effective communication an
essential skill in nursing professional practice (Apker et al., 2006). Suter, Arndt, Arthur,
Parboosingh, Taylor, and Deutschlander (2009) interviewed health care professionals
from seven health care sites across Alberta on interdisciplinary practice; communication
was emphasized as one of the dominant competencies of successful CP. They found that
"good formal and informal communication among providers . . . is key to collaborative
patient-centered care and, specifically, to care coordination" (Suter et al., 2000, p. 46)
and conversely that a lack of communication between providers hampered collaboration.
Morse and Piland (1981) conducted a large-scale survey involving RNs employed
at four American midwestern metropolitan hospitals. They found that the RN-RN
relationship was complex and that communication skills were considered of primary
importance for a successful nurse-nurse relationship. The most important communication
competency reported was interpersonal communication, which was defined by the nurses
as listening, routine information exchange, conflict management, and small group
communication.
Suter et al. (2009) found that communication failure has consistently been linked
to patient harm. The Joint Commission on Accreditation of Healthcare Organization
(2007, as cited in Suter et al., 2009) documented that communication failure was one of
the leading causes of approximately 65% of the sentinel events reported and that "poor
information transfer and discontinuity of care have been found to lower quality at follow-
up and increase adverse clinical outcomes." (p. 49). The Canadian Medical Protective
Association (2007) reached a similar conclusion, in that "poorly functioning teams, in
particular poorly communicating teams, increase the safety risks for patients" (p. 1).
Coding and Cukr (2000) noted a positive correlation between effective
communication and collaboration, improved quality of care, and RN satisfaction in an
interactive study. They found that the failure to collaborate was not due to ill intent, but
due to lack of communication skills. The study identified three communication styles
(attentive, contentious, and dominant) and showed that use of the attentive style increased
RNs' perception of effective communication. Contentious and dominant communication
styles were reported as communication styles to be avoided, because they were shown to
have a negative impact on effective communication.
In a qualitative analysis of interview transcripts at a large tertiary hospital, Apker
et al. (2006) described four communicative skill sets exemplified by RNs: collaboration,
compassion, credibility, and coordination. They provided sample verbal and nonverbal
techniques characteristic of each of the four communication skill sets. The study
emphasized that teaching good communication is an important standard of nursing
education and provided recommendations as to how nursing management can facilitate
effective communication among team members. Role modeling, communication in-
service education, interactive simulations using video and CD-ROM visual aids,
preceptors who embody excellent communication qualities, and organizational policies
that encourage positive communication were identified as strategies for nurse managers
to use.
Communication and Leadership
Leaders can foster relationships through better listening, conversing and
respecting each other as individuals (Wheatley, 2007). "Effective communication is the
foundation for several leadership competencies, such as building relationships, managing

conflict, and developing other people" (Gentry & Kuhnert, 2007, p. 4). Bolden and
Gosling (2006) defined leadership as a "language game . . . [in which] effective leaders
put words to the formless longings and deeply felt needs of others. They create
communities out of words" (p. 154). Cuno (2005, as cited in Bolden & Gosling, 2006)
stated that "one often hears that leaders lead through action, by example. But more often,
and often more effectively, leaders lead through their words, by acts of speech" (p. 154).
Schnurr (2008) agreed with this perspective, commenting that
it appears that communication affects leaders' effectiveness on various levels

since many of the central leadership activities, such as creating and
communicating a vision, encouraging, motivating, and guiding subordinates,
setting a goal and ensuring subordinates' compliance all involve communication
skills, (p. 300)
Therefore, leaders can positively impact how staff work in a team environment through
the use of effective communication practices.
I communicate consistently with staff and employ several different methods of
communication. According to Krell (2001), "employees like email and voicemail, but
only as a back up to face-to-face communication." (p. 68). Krell additionally stated that
employees like to get communication from their immediate manager. I disagree slightly
with this statement, for while I agree that communication from one's direct manager is
important, I also think it is important for staff to hear about initiatives from the
organization's senior leadership team perspective and be provided the opportunity to ask
this team questions directly. In order to build a committed workforce, employees must
view their role as crucial to the success of the organization. Employee pride,
commitment, and productivity are facilitated through effective internal communication
(Conference Board of Canada, 2002).

Summary
The modern nursing paradigm requires nurses to successfully enact traditional
communication processes (such as education and empathy) with patients as well as their
families and demonstrate new communication skills (such as conflict resolution and
change management) when interacting with their coworkers (Apker et al., 2006). The
literature review supported the idea that effective communication is a vital aspect of a
positive nursing practice environment and effective leadership and identified the essential
components of effective communication. The research, though, has focused on RN-RN
communication; there is a lack of research related to effective communication strategies
between the different nursing disciplines (e.g., RN to LPN and PCA) in a CP nursing
environment and little research as to how nurse managers can help facilitate this effective
communication. However, the strategies identified for positive RN-RN communication
can be applied to RN-LPN-PC A communication in the ACE unit at VGH to help
facilitate effective team communication. As Faulkner (1998) stated, "To be able to
communicate effectively with others is at the heart of all patient care" (p. 1).
Trust
Today's health care environment is challenging, fast paced, and demanding.
There is currently tremendous pressure to make changes in the health care system to
control costs while at the same time contend with the growing needs of patients and the
forecasted staff shortages. According to Solomon and Flores (2001), "trust is a way of
dealing with complexity in an increasingly complex society . .. allowing us to explore in
new directions . . . it allows us to grow and change" (p. 9).

Definition of Trust
Akhavain et al. (1999) defined trust as a "positive belief in and dependence on the
competency of another and a firm confidence that another's actions and behaviors are
governed by right and moral motives" (p. 2). Lee and Teo (2005) believed that trust
"exists between two parties when one party believes that the other party is . .. willing to
be vulnerable to the other" (p. 27) and therefore defined trust as "the willingness to take
risks and be vulnerable to the actions of others based on the assumption that the other will
act in a manner beneficial to the trustor" (p. 27). Atkinson and Butcher (2003) stated that
"Ironically, scholars concur that there is little agreement on the meaning of trust" (p.
283). Although there is overwhelming consensus that trust is a crucial and important part
of people's everyday lives and impacts them personally and professionally, an agreed-
upon definition does not exist.
Trust and Collaboration
According to Henneman et al. (1995), the literature on the concept of
collaboration shows that collaboration flourishes in an atmosphere where there is a high
level of trust among the disciplines; team members can assume accountability and
responsibility for patient care more easily when trust and respect for individual
perspectives are part of the team's culture. Conversely, a lack of trust is an
insurmountable barrier to collaboration.
Trust is something that must be learned, it is a dynamic social process that is
transformative in reciprocal relationships and requires constant work (Soloman & Flores,
2001). Developing an environment of trust and collaboration requires that each team
member relinquishes any notions of a hierarchy based on intellectual superiority. This is

important for CP; it is indicates that it is essential for each team member, whether an RN,
LPN, or PCA, to understand not only his or her individual role and responsibilities, but
also those of other team members. Team members must respect and recognize the body
of knowledge, talent, skills, and abilities of each discipline. Trust, which is earned over
time, requires patience and effort (Henneman et al., 1995).
Trust, Leadership, and Change
In order to meet the ever-increasing demands on the system, the workplace has
transformed from a place where one to two change initiatives are contemplated a year to
one continuous change initiative. CP is one of these change initiatives. "Change fatigue"
has emerged as the new buzz word to describe how health care staff are feeling about this
new organizational reality. Change fatigue is described as a "result of relentless change,
during which employees lose trust.... change fatigue threatens realizing the vision"
(Reineck, 2007, p. 388). Trust is critical for change, because "trust allows us to grow and
change" (Solomon & Flores, 2001, p. 9). If staff members feel that their leaders can be
trusted to support new values and actions, they will be more willing to commit time and
effort and take risks (Senge, 2006). Sometimes, "trust in the leader is the only anchor
employees have during continuous change" (MacPhee, 2007, p. 406).
Leader behaviours that are indicative of trust are strategically important to the
organization. Laschinger and Finegan (2005), when exploring health care employees'
perceptions of trust in management, found that "creating and sustaining trust throughout
the organization was identified as a critically important leader activity" (p. 6). However,
Williams (2005), while studying trust and leadership, imparted the idea that "our efforts
to bridge research and practice in management lags behind what we expect of the
clinicians who practice in our organizations" (p. 203). Impersonal trust, which is based
upon roles or reputations, may be all that is required for many of the practical purposes
within an organization (Atkinson & Butcher, 2003).
Leadership is not about personality or titles; it is about behaviour (Kouzes &
Posner, 2002. Five behaviours that managers can exhibit to increase their perceptions of
trustworthiness among employees are behaviour consistency; behaviour integrity; sharing
of control; accurate, open, and thorough communication; and a demonstration of concern
(Kramer & Cook, 2007). "Without trust you cannot lead" (Kouzes & Posner, 2002, p.
224)
Summary
Throughout this literature review, I found no evidence to contradict the vital
importance of trust in all aspects of life. The review shows that having trust in each other,
whether among teams members or employees and management, is a key pillar of any
collaborative work environment.
Conclusion
The literature review analyzed three areas of focus pertinent to the research
question. Key terms and concepts were identified related to CP, communication, and
trust. The following chapter outlines the research approach and methodology, including a
discussion on how the research was conducted.

CHAPTER 3: RESEARCH APPROACH AND METHODOLOGY
The following chapter provides an overview of the research process, including a
review of the research approach, identification of the research participants, and
discussion of the research methods used. The chapter concludes with a detailed review of
the ethical issues and their relation to the conduct of this study.
Research Approach
This research project sought to answer the following question: How can leaders
facilitate effective team communication between nursing staff (i.e. RN, LPN, PCA) in an
ACE unit and a collaborative practice environment?. Throughout my career in health
care, I have seen the challenges, such as decreased teamwork and support, which confront
nursing staff as a result of ineffective communication.
I conducted this research project using qualitative and quantitative research
methods. In general, qualitative research generates rich, detailed, and valid (process) data
that contribute to an in-depth understanding of context, whereas quantitative research
generates reliable population-based and generalizable data and is well suited to
establishing cause-and-effect relationships. Palys (2003) stated that "more and more
researchers now acknowledge the benefits of incorporating both types of data into any
piece of research . . . thereby more fully exploiting the strengths and overcoming the
limitations of each" (p. 22).
I chose action research as the research methodology for this study. Action
research is a "systematic approach to investigation that enables people to find effective
solutions to problems they confront in their everyday lives" (Stringer, 2007, p. 1). It is
based on the premise that general solutions may not fit specific contexts or groups of
people; action research focuses on specific situations and localized solutions. The
primary purpose of action research is to "provide the means for people to engage in
systemic enquiry and investigation to design an appropriate way of accomplishing a
desired goal and to evaluate the effectiveness" (Stringer, 2007, p. 6). Action research is
advantageous because it allows the researcher an opportunity be become immersed in the
setting and culture of the current environment, thereby allowing the researcher intimate
interaction with the participants (Stringer).
Community-based action research, where the community is defined as a
community of interest, presumes that "all people who affect or are affected by the issue
investigated should be included in the process of inquiry" (Stringer, 2007, p. 6). I felt that
it was important to include RNs, LPNs, and PCAs as part of the community of interest for
this research project so that they could contribute to positive communication strategies
for the units. Engaging the nursing staff in action research encouraged them to feel
empowered; action research unleashes energy, stimulates creativity, instils pride, builds
commitment, prompts the taking of responsibility, and evokes a sense of investment and
ownership by participants (Stringer, 2007). Action research does not impose change; it
stimulates people to change.
Effective nursing team communication is a vital aspect of a positive nursing
practice environment (Apker et al., 2006). When there is clear, mutually understandable
communication between nursing team members, the team is able to work in a
collaborative manner to provide quality patient care, which is necessary for good patient
outcomes (Milligam et al, 1999). I hoped that by engaging the ACE nursing staff in this
research project, they would gain the knowledge and tools necessary to facilitate change
and transition in an effective, high-functioning, collaborative team, where working
together results in the provision of quality patient care. I chose action research because it
is based on a collaborative problem-solving approach between researcher and participant
and aims to not only solve a problem, but also generate new knowledge (Coghlan &
Brannick, 2007). This aligns with the vision of VCH (2007)..
The role of the action researcher is one of collaboration. The action researcher,
rather than acting as an expert, acts as a facilitator, consultant, catalyst, and associate
(Stringer, 2007). The strength of action research is that it provides an opportunity for
"team learning and change .. . which is pursued through collaboration" (Hall, 2006, p.
195). The approach of action research is in alignment with my personal leadership
philosophy of collaboration and facilitation.
Project Participants
Critical reference groups are stakeholders primarily concerned with and
influenced by the project's research focus (Stringer, 2007). I identified three critical
reference groups as project participants for this research: the RNs, LPNs, and PCAs in the
ACE unit at VGH.
I selected participants purposefully using the following two criteria: functional
role and availability. Patton (2002, as cited in Glesne, 2006) stated that purposeful
selection leads to "selecting information-rich cases for study in depth. Information-rich
cases are those from which one can learn a great deal about issues of central importance
to the purpose of the research" (p. 34). Staff from each functional nursing discipline (RN,
LPN, PCA) were invited to participate. The frontline leadership team (who are also RNs)
from the ACE program were also invited to participate in order to capture their
perception of communication within the CP team environment.
Research Methods
I chose two methods of inquiry for this research project and collected data using
an Internet-based survey and focus group interviews. Berg (2004) stated that by
combining different methods of inquiry, researchers will obtain a richer, more substantive
collection of data, as each method reveals slightly different facets of the same issue.
Survey
The first research method used was the survey. I employed an Internet-based
commercial survey tool called Survey Monkey to conduct the survey. This commercial
survey tool is the product of an American company, so the data are held in the United
States and subject to the Patriot Act. I informed participants of this information prior to
completing the survey. I met with my research advisory team to develop and review the
survey questions prior to conducting the survey to ensure that the survey questions were
not biased or influenced by my perceptions and perspectives (Stringer, 2007).
The goal of the survey was to determine the existing nursing team communication
environment within the ACE unit (one of my research subquestions), because
understanding this environment was necessary to address the research question. A
structured questionnaire was developed, asking closed-ended questions. A specific
question asked which nursing discipline the participant belonged to, ensuring that data
obtained through both data collection methods could be linked and compared by
discipline, thereby strengthening the quality of the data.

E-mail is the primary communication method used to contact staff in the ACE
program, so this method was used to invite prospective participants. All staff have a VGH
issued e-mail address and access to a computer and the Internet in their work
environment. A letter of invitation to participate in the research project was sent out via
e-mail to all ACE RN, LPN, and PCA staff (see Appendix A). The letter of invitation
included the following points: who the researcher was, the focus of my research and why
it was being done, what would be done with the results, the methods used to select
participants, the potential benefits and risks to participants, confidentiality assurances,
expected frequency of interactions, expected duration of interactions, and request for
permission to record data (Glesne, 2006).
A hyperlink to the Internet-based survey was embedded in the e-mail. Interested
participants were able to click on the hyperlink to complete the survey. The first step in
the survey had participants answer a question addressing informed consent and
confidentiality (see Appendix B). If participants did not agree to the terms of informed
consent and confidentiality, they were unable to proceed to complete the survey.
Letters of invitation were sent to 105 nursing staff members (a combination of
RNs, LPNs, and PCAs) who work in the ACE unit. The average survey response rate for
a sample size of fewer than 1,000 survey invitations is 32.52% (Hamilton, 2008).
Through informing the staff of the research project prior to the project starting and the
flexibility that the Internet-based survey tool allowed (privacy and anonymity of
participants, 24-hour access) (Palys, 2003), I hoped that at least 35% of those invited
would participate. The final number of survey participants was 38 (36.19%) and the
mixture reflected the staffing mix in the program.

The survey consisted of 14 questions (see Appendix C), with an estimated
completion time of approximately 15 minutes. Questions allowed participants the
opportunity to provide feedback on the current state of communication between nursing
team members in the ACE unit. This included the use of a four-level Likert scale, which
is a type of rating scale used to indicate the level of agreement or disagreement that the
participant has with the stated assertion (Palys, 2003). The survey results provided me
with a starting point and guided the discussion in the focus groups. Some of the questions
asked in the focus group were created based on the responses generated in the survey.
Focus Groups
The second research method used was the focus group. Berg (2004) noted that in
settings such as a hospital, due to the semitransient nature of the employee population
(e.g., shift work, rotating schedules), focus groups work well as a data collection method
(Berg, 2004). He went on to state that focus groups are energetic and dynamic,
interactions between participants stimulate discussion, and this synergy and interaction
between participants leads to the brainstorming of ideas and generation of solutions. The
survey responses helped to guide the focus groups, which reflects the continuous cycle of
action research (diagnosing, planning action, taking action, evaluating action, then
looping back to diagnosing and starting again).
The focus groups were a mixture of representatives from each of the stakeholder
(RN, LPN, PCA) groups. Although I recognized that there was the potential for a power
imbalance between the different stakeholder groups, which could result in participants
not speaking openly or feeling uncomfortable in disclosing information, I felt that as the
research study focused on enhancing communication between nursing team members, it

was important for representatives from each of the different disciplines that make up the
team be present in the focus group. I ensured that as facilitator for the focus group I was
aware of the potential for a power imbalance and had beforehand identified potential
strategies to minimize this obstacle.
I developed, reviewed, and pilot tested the focus group questions in advance with
my research advisory team. I formulated the questions using words familiar to the
participants and designed them to assist in answering the research subquestions.(see
Appendix D)
For the focus groups, invitations to participate were sent to the same 105 staff
members who had received invitations to participate in the survey (see Appendix E).
Interested participants were able to respond back to me via e-mail. Glesne (2006) stated
that small groups of four to six participants work best for focus groups, with a meeting
time of 90 minutes. I organized two focus group sessions, each with five participants.
There was representation from each nursing discipline (RN, LPN, PCA) at each focus
group. I held the sessions away from the unit, and each lasted approximately 1 hour,
because the necessary number of research participants agreed to participate in the focus
groups, I did not use additional methods to recruit research participants. I handed out an
informed consent and confidentiality form to participants at the beginning of the focus
group, and each participant signed an original copy of the form prior to the focus group
commencing (see Appendix F).
I conducted the focus groups in a semistandardized manner. As facilitator, I asked
participants open-ended questions in a planned and systematic order. Berg (2004) stated
that the sequencing of the questions can significantly affect the results and suggested that
the questions begin with a mild, nonthreatening question (such as those concerning
demographic data). These questions were easy for the participants to answer and allowed
me to develop rapport with the participants. As the focus group proceeded, I asked more
complex and sensitive questions. As in semistandardized interviews, I also had the
freedom to digress from the planned structure of the discussions and probe beyond
participant answers (Berg).
The nonthreatening ambience of the focus group allowed the participants to
engage in thoughtful and collaborative dialogue. Open dialogue was encouraged;
thoughts, ideas, and perceptions flowed freely. This is consistent with my personal
philosophy of open learning.
Validity and Reliability of Data
Validity and reliability are important aspects of any research. Validity is defined
as "whether research measures what the researcher thinks is being measured." (Palys &
Atchison, 2008, p. 430). Reliability is demonstrated when "repeated observations of a
phenomenon . . . yields [sic] similar results" (Palys & Atchison, 2008, p. 427). I achieved
triangulation to ensure the validity and reliability of the research data, using the following
forms of triangulation: multiple data collection methods (surveys and focus groups),
multiple data sources (frontline leaders, RNs, LPNs, PCAs), multiple investigators (the
research team), and multiple theoretical perspectives (evidenced in the literature review)
(Glesne, 2006).
Study Conduct
During the fall of 2008,1 discussed the research proposal with the leadership of
the ACE program. After receiving ethics approval of the Major Project Proposal from
Royal Roads University and VCH in January 2009,1 informed the ACE leadership team
that research would commence.
As the researcher, I collaborated with the research advisory team to develop and
review survey questions in February 2009.1 then pilot tested the questions with members
of the stakeholder groups, where these members were not participants in the research
study and were comfortable providing feedback. Pilot testing questions is important
because "there are always things you take for granted without recognizing, and there are
always surprises you never considered when constructing the questionnaire" (Palys,
2003, p. 187). It was important to be aware of and catch these challenges before starting
the data collection, rather than finding out halfway through and having to start afresh.
Through e-mail, RNs, LPNs, and PC As in the ACE unit were informed of the research
study and invited to participate. The survey was conducted for a period of 4 weeks in
March 2009. No reminders were sent during the course of the survey.
Upon reviewing the survey data, focus group questions were created. The
research advisory team reviewed these questions in April 2009. Two focus groups were
held in April 2009. The focus groups were audiotaped, and I hired a transcriptionist to
transcribe the audiotapes. Participants received copies of the transcription to review for
accuracy and validation. In addition to audiotapes, a recorder attended the focus sessions
and recorded data via written notes. Potential bias was addressed by having the recorder
come from outside the research team and ACE program, so the recorder did not have
preconceived ideas regarding the topic. The recorder signed a confidentiality agreement
(see Appendix G). Bias was also addressed by comparing the recorder's written notes to
the audiotapes. Participants in the focus group were also asked to help theme the data at
the end of the focus group session. An analysis of the survey data and focus group data
was then performed.
As the researcher, I facilitated the focus group session. I was concerned that my
position of authority would unduly influence staff participation. For example, staff may
have felt obligated to engage in the research project, may have believed that there would
be positive (favouritism) or negative repercussions to participating in the study, or may
not have felt comfortable speaking freely. I asked one of my research team members to
participate in the focus group sessions to act as an observer to ensure quality of data.
However, doing action research in your own organization is political; I journalled
throughout the research process, as it is a valuable tool that encouraged me to reflect on
these issues (Coghlan & Brannick, 2007).
Data Analysis
I used content analysis to analyze the data collected from the surveys and focus
groups. Content analysis can be applied to qualitative and quantitative communication
and is defined as "any technique for making inferences by systematically and objectively
identifying special characteristics of messages" (Hoist, 1968, as cited in Berg, 2004, p.
267). Data analysis is accomplished by means of explicit rules called criteria of selection,
which are established prior to the commencement of data analysis. Criteria of selection
must be "sufficiently exhaustive to account for each variation of message content and
must be rigidly and consistently applied so that other researchers . . . looking at the same
messages, would obtain the same or comparable results" (Berg, 2004, p. 268).
As recommended by Berg (2004), I analyzed the data in the following manner: I
identified the research question; the research team and I read the literature and data to
identify analytic categories and grounded categories and ensured that the identified
themes and category labels related back to the research question; we established objective
criteria of selection; I manually sorted the data, using visual aids such as tally sheets; we
looked for patterns in the data, ensuring that there was a minimum of three occurrences
for something to be considered a pattern; and finally I explained the data, aligned it with
the literature, and described differences and similarities. This last step was the most
challenging step in the process (Berg).
Trustworthiness
As an action researcher, I needed to engage in systematic and rigorous research
processes to ensure that my research was sound. In traditional research, the basis for
rigour is founded through the establishment of reliable and valid research. In action
research, rigour is based on trustworthiness; trustworthiness ensures that the outcome of
the research does not just reflect the perspective or bias of the researcher and that the
outcomes are not based on superficial or simplistic analysis of the issue (Stringer, 2007).
In action research, checks for trustworthiness are "designed to ensure that
researchers have rigorously established the veracity, truthfulness, or validity of the
information and analyses that have emerged from the research process" (Stringer, 2007,
p. 57). I established trustworthiness through credibility, dependability, and
confirmability.
Credibility is a fundamental issue in action research. Participants need to be able
to trust the integrity of the processes. Through actions such as taking the time to explain
the research to the participants, answering their questions, allowing them to review the
data, and debriefing with them after the research was completed, I helped foster
credibility (Stringer, 2007).
Dependability focuses on whether or not participants trust that I have followed all
measures required of a systematic research process. Providing an inquiry audit describing
to the participants the details of the procedures that had been followed helped increase
dependability (Stringer, 2007).
As a researcher, I must be able to confirm to participants that the procedures that I
outlined to them actually took place. An audit trail comprised of tapes, written notes,
signed confidentiality agreements, and other artefacts related to my research study helped
confirm the veracity of the study and assured participants that the research was
trustworthy (Stringer, 2007).
Ethical Issues
As action research involves human participants, I adhered to the guidelines as set
out in Royal Roads University's (2007) Research Ethics Policy and ensured ethical
obligations were met during the research project. Upon review of the Royal Roads
University policy and the Canadian Institutes of Health Research, Natural Sciences and
Engineering Research Council of Canada, & Social Sciences and Humanities Research
Council of Canada's (2005) Tri-Council Policy Statement on Ethical Conduct for
Research Involving Humans, it was evident that the guiding ethical principles for both
policies are the same. These principles are derived from policy statements from national
and international agencies. They express common values, aspirations, and standards of
the national and international research communities. These principles are Respect for
Human Dignity, Respect for Free and Informed Consent, Respect for Vulnerable Persons,
Respect for Privacy and Confidentiality, Respect for Justice and Inclusiveness, Balancing
Harms and Benefits, Minimizing Harm, and Maximizing Benefit.
Respect for Human Dignity
Respect for Human Dignity is considered to be the cardinal rule of modern
research ethics. It contends that the interests of the person, from psychological to bodily
to cultural integrity, be protected (Canadian Institutes of Health Research, Natural
Sciences and Engineering Research Council of Canada, & Social Sciences and
Humanities Research Council of Canada, 2005). In my research project, I strove to
adhere to this principle by ensuring that any participants in the research project did not
feel coerced or pressured into participating in the project. I was aware of how the project
participants may view my position of authority in the organization and made sure that
there was no positive (favouritism) or negative repercussions to staff members, regardless
of whether they chose to participate or not, or if they chose to withdraw from the project
after it started. By being transparent to the participants in regards to the purpose of the
research and why data were being collected, I circumvented any potential obstacles.
Respect for Free and Informed Consent
Respect for Free and Informed Consent meant that I provided full disclosure
regarding my research project, so that participants made a voluntary, fully informed
decision about their participation. I did not offer incentives, such as monetary
remuneration, to participate in the project, nor did I coerce staff into participating by
using my position of authority in the organization. Glesne (2006) stated that while
"informed consent neither precludes the abuse of research findings, nor creates a
symmetrical relationship between researcher and researched, it can contribute to the
empowering of research participants" (p. 132).
Respect for Vulnerable Persons
I ensured that the principle of Respect for Vulnerable Persons was met by
reviewing the participants in the project and assessing for people whose situation,
diminished competence, or diminished decision making could make them vulnerable or
exploited in the context of the research. If considered vulnerable, this person would be
unable to give free and informed consent. I was also aware that vulnerability is
considered to be dynamic, so I continuously assessed this issue throughout the research
project (Canadian Institutes of Health Research, Natural Sciences and Engineering
Research Council of Canada, & Social Sciences and Humanities Research Council of
Canada, 2005).
Respect for Privacy and Confidentiality
Privacy and confidentiality are considered by many cultures to be a fundamental
aspect of human dignity. Privacy in research refers to how investigators collect or access
data from participants; confidentiality refers to agreements between the investigator and
participant about how the data collected will be handled and who they will be released to
(Goldman & Choy, 2006). Privacy and confidentiality are two of the primary concerns
for research participants, and participants expect that these aspects will not be breached
(Glesne, 2006). For my research project, I strove to ensure privacy through such means as
holding focus groups away from the inpatient units, using a third-party survey company,
and managing data so that they could not be linked back to a specific participant.
Confidentiality agreements were signed between me, the recorder, the transcriptionist,
and all research participants in order to minimize the risk of confidential data being
exposed, and prior to the implementation of the project; it was fully disclosed who the
data would be released to. I stored collected data in a secure area.
Respect for Justice and Inclusiveness
Respect for Justice and Inclusiveness was met by having the appropriate ethics
boards (Royal Roads University and VCH) review and sign off on my research proposal
prior to initiation of the project. This review process , ensured that no individual or group
of participants would be exploited for the advancement of knowledge.
Balancing Harm and Benefits
The Balancing Harm and Benefits principle means that the anticipated benefits of
the research project outweigh the foreseeable harm. Anticipated benefits included the
development of a communication framework that enhances dialogue between nursing
staff; foreseeable harm included undue pressure and burden on the participants to acquire
this specific knowledge. By being aware of this balancing act throughout the research
project, I was able to stay attuned to any imbalances where harm outweighed the benefits.
Minimizing Harm
Minimizing Harm was achieved through not exposing the participants to
unnecessary risks. For example, data collection methods must not place undue pressure
on participants and it must be acknowledged that the participant's involvement in the
research is essential to the realization of the project. The minimum number of participants
required to provide scientifically valid data was used. I recognized that due to my
position of authority in the program, staff may have felt pressured and obligated to
participate in the research. To minimize this potential risk, I communicated to staff
members that they were free to participate or not and respected their decision.
Maximizing Benefits
The principle of Maximizing Benefits had relevance for my research project,
because the benefits realized through this project directly impacted the participants.
Strategies that leaders can use to facilitate communication between nursing team
members were recommended. The organization also benefited, as CP is being
implemented organization wide; the results of my research project can be applied to
future CP initiatives.
Conclusion
Through the collection of qualitative and quantitative data using a survey and
focus groups, I used the cyclical process of action research as a method of answering the
research question: How can leaders facilitate effective team communication between
nursing staff (RN, LPN, PCA) in an ACE unit and a CP environment? Through
triangulation of the data, validity and reliability of the research data were ensured. I
reviewed and considered ethical issues throughout the research process and strove to
ensure the project was conducted in a consistent, ethical manner.
The following chapter provides an in-depth overview of the research findings.

CHAPTER 4: ACTION RESEARCH PROJECT RESULTS AND CONCLUSIONS
The research project sought to answer the question, "How can leaders facilitate
effective communication between nursing staff (RN, LPN, PCA) in a collaborative team
practice environment on an Acute Care for Elders unit?" In addition, it sought to identify
what factors contribute to the current state of communication in the unit and what skills
are needed to facilitate effective communication. This chapter reviews the study findings,
conclusions, and limitations of the research project.
Study Findings
Survey Findings
The survey questioned RNs, LPNs, PCAs and patient care coordinators (PCCs) on
their perception of the current state of communication on the ACE unit. PCCs are RNs
and the frontline leadership on the unit. Of the 105 invitations sent, 38 staff members
responded. This was a response rate of 36.19 %, which was sufficient enough to draw
representative conclusions (Hamilton, 2008). The highest response rate was from RNs;
25 (67.6%) took part in the survey. In addition, 3 LPNs (8.1%), 7 PCAs (18.9%), and 2
PCCs (5.4%) completed the survey. The survey respondents were a representative sample
of the staff mix in the ACE program (The ACE program staff mix is 62% RNs, 14%
LPNs, and 24% PCAs.).
The highest percentage of participants came from staff with 5 to 10 years of
experience in health care (28.9% of respondents); just under half (48.6%) of the
respondents had worked on the ACE unit between 2 and 5 years (see Figure 1).
Number of Years Worked
60% T-- -
50%
» 40%
HACEUnit
• Healthcare
10%
0%
Less than one year One to two years Two to five years Five to ten years Ten to twenty years Over twenty years
Figure 1. Respondents' number of years of work experience.
The majority of the survey questions were designed to elicit responses to
determine the current state of communication on the ACE unit as perceived by the
nursing staff. When asked if the current workplace environment facilitated open
communication, 21.6% of respondents strongly agreed, 54.1% agreed, and 24.3%
disagreed. No respondents strongly disagreed. Table 1 details the survey questions asked
and the participant responses.

Table 1. Responses to Survey Questions
___ Questions Strongly agree Agree Disagree Strongly disagree

The workplace environment facilitates open
communication. 21.6% 54.1% 24.3% 0.0%
Unit leadership encourages open communication. 42.9% 48.6% 8.5% 0.0%
Effective communication is essential in
providing safe patient care. 57.1% 42.9% 0.0% 0.0%
During my shift, enough information is
communicated to me from other team members
to provide safe patient care. 11.1% 66.7% 22.2% 0.0%
At shift change, enough information is
communicated to me from other team members
to provide safe patient care. 11.8% 67.6% 20.6% 0.0%
I have the necessary skills to communicate
effectively with team members. 22.8% 74.3% 2.9% 0.0%
Team members have the necessary skills to
communicate effectively with me. 14.3% 51.4% 34.3% 0.0%
I have the necessary skills to communicate
effectively with unit leadership. 25.7% 71.4% 2.9% 0.0%
Unit leadership has the necessary skills to
communicate effectively with nursing staff. 27.7% 63.9% 5.6% 2.8%
Survey results were also tabulated according to nursing profession. Appendix H
outlines the survey responses broken down by nursing profession.
The survey showed that the majority of respondents (75.7%), regardless of
nursing profession, felt that the workplace and unit leadership encouraged open
communication. Respondents who disagreed that the workplace environment facilitated
open communication included RNs, LPNs and PCA, with LPNs having the highest
percentage among this group of respondents.
The majority of survey respondents (91.5%) answered that the unit leadership
encouraged open communication. All respondents either agreed or strongly agreed that
effective communication was essential in providing safe patient care (no respondent
disagreed or strongly disagreed). Approximately 80% of respondents answered that they

were communicated enough information during their shift and at shift change to provide
sage patient care.
It is interesting to note that 97.1% of respondents answered that they had the
necessary skills to communicate effectively with their team members, but only 65.7%
responded that team members had the necessary communication skills to communicate
effectively with them. Breaking this down by nursing profession, 95.6% of RN
respondents, 100% of LPN respondents, 100% of PCA respondents, and 100% of PCC
respondents strongly agreed or agreed that they had the necessary communication skills
to communicate effectively with their team members. In contrast, 52.5% of RN
respondents, 66.7% of LPN respondents, 100% of PCAs, and 100% of PCC respondents
answered positively that their team members had the necessary communication skills to
communicate effectively with them. The majority of respondents also answered that
communication with the unit leadership was effective.
Focus Group Findings
Focus Group A
The first focus group was held on April 7, 2009, between 15:00 and 16:00.1
facilitated the focus group, which consisted of 1 RN, 1 LPN, 1 PCA, 1 PCC, and a
recorder. Each of the nursing staff had been working on the same ACE unit for
approximately 2 years. The recorder had no affiliation with the ACE unit.
The introductory component of the session included an overview of the research
project, a description of action research, and the intended goals of the focus group. When
asked to state one word that described the current state of communication on the unit,
participants used the words "open," "easy," "flexible," and "effective." Participants stated
that they preferred verbal communication to written communication, because verbal
communication allowed a person to clarify any questions at that moment. Verbal
communication also allowed for an understanding of the nuances of the conversation,
such as tone of voice and body language of the communicator and listener. Participants
felt that the written word was sometimes harder to interpret and understand, especially as
not all staff have English as their first language.
Participants communicated with other team members throughout the shift;
communication happened on an as-needed basis, not at preset times. Participants viewed
communication as the tool to clarify respective roles, clarify each team member's
responsibilities, and determine what each team member could do for each other that shift.
What are some of the challenges within the nursing team that impact the ability to
communicate effectively in a collaborative practice environment? Responses offered by
participants to this question were comprehensive and included the following themes:
1. New staff: Participants stated that there is constant staff turnover on the unit. They
felt that when new staff members are hired to the unit, the individuals may be
unclear as to their role and responsibilities and unfamiliar with the unit routine,
thereby impacting communication.
2. Casual staff: Participants stated that often casual staff did not have the same high
work ethic as evidenced by regular staff. Participants felt that casual staff, due to
their irregular work schedule and the fact that they work on multiple units, also
did not want to collaborate with regular staff, which negatively impacted
communication.
3. Workload: Participants acknowledged that when it was busy on the unit,
communication was not as effective, due to the fact that staff felt that they did not
have the time to communicate effectively with other team members.
Participants felt that patient acuity did not negatively impact communication; in
fact, they stated the opposite. Participants stated that they communicated more effectively
when the acuity of the patient increased, because they had to be more aware of and
attentive to the patient, which afforded them the opportunity to provide more detailed
information to team members.
Do you communicate differently when you are communicating within your
nursing discipline (e.g., RN to RN) as compared to when you communicate with another
nursing discipline (e.g., RN to LPN)? If so, what is the difference? All participants
agreed that they communicated differently when they were communicating within their
nursing discipline as compared to communicating with another nursing discipline.
Participants stated that the difference was in the detail of the information communicated;
they "convey what is relevant." Participants responded that each nursing discipline
required a different type of detailed information. For example, RNs would communicate
detailed information regarding pain medication for a patient such as dosage, time of
administration, and effectiveness of medication to another RN, but when communicating
to a PCA, the RN would say only that the patient had pain medication due at a specific
time.
Thinking of an example of poor communication between nursing team members,
what do you see as the contributing factors that made it poor communication? Responses
from participants were divided into two themes:

1. Nonverbal communication traits: Participants identified nonverbal communication
traits that negatively impacted communication, including angry facial expression,
gestures such as finger pointing, loud tone of voice, closed body posture, not
looking the other person in the eye, and crowding (i.e. lack of personal space).
2. Disrespect: Participants stated that communication was challenging when a staff
member showed disrespect for another staff person's role on the unit. Disrespect
could be shown by one team member being dictatorial (rather than collaborative)
or not listening when the other team member was talking.
Thinking of an example of good communication between nursing team members,
what do you see as the contributing factors that made it good communication? When
theming the responses for this questions, the overarching theme was trust. Participants
felt that trust was the key to effective communication, and this trust needed to be
reciprocal between the team members: "We need to be able to trust our co-workers, to
know that we can depend and rely on them."
What skills do team members need to communicate effectively? Participants
responded that team members need to speak clearly and concisely, listen, be empathetic,
and "clarify when they don't understand something so they don't jump to conclusions" in
order to communicate effectively.
What do you perceive are the barriers to facilitating effective communication
between nursing staff in a collaborative practice environment on an ACE unit? Answers
to this question by participants were comprehensive and when themed, they included the
following:
1. Workload: Participants felt that when the workload was heavy on the unit, they
did not have the time to communicate effectively; they did not have time to
"prepare" to communicate and did not have time to complete written
communication tools such as the nursing kardex or census sheet.
2. Physical environment: Participants acknowledged that due to the physical layout
of the unit (it is a U-shape), they often have to spend time searching for the team
member that they wish to speak to. They also felt that when the workspace was
disorganized (patient charts and equipment not put away), they had to spend time
locating information sources such as patient charts, leaving them less time to
communicate and therefore making communication rushed.
What do you perceive are the solutions to facilitating effective communication
between nursing staff in a collaborative practice environment on the ACE unit?
Participants all stated that having the opportunity to partake in continuing education
courses in communication would facilitate effective communication. Participant felt that
the organization should offer support to nursing staff, through the provision of
communication courses, education leave to take communication courses offered outside
the organization, and/or financial resources to implement new communication tools.
In closing, a participant stated, "Good communication makes us a better team,
which results in better patient care."
Focus Group B
The second focus group was held April 23, 2009, from 1500 to 1600.1 facilitated
the focus group, which consisted of 1 RN, 1 LPN, 1 PCA, 1 PCC, and a recorder. The
nursing staff had been working on the same ACE unit for between 2 and 6 years;
however, the ACE unit was a different unit than the one the staff worked on in focus
group A (both ACE units were part of the same ACE program at the same hospital). The
recorder had no affiliation with the ACE unit.
The participants in focus group B were not apprised of the results of focus group
A. As with focus group A, the introductory component of the session included an
overview of the research project, a description of action research, and the intended goals
of the focus group. When asked to state one word that described the current state of
communication on the unit, participants used the words "effective" and "challenging."
Three participants (RN, LPN, and PCA) stated that they preferred written tools to
communicate information, such as the nursing kardex and census sheet, and used verbal
communication only when clarification of an issue was needed or when they were giving
a report to another team member before leaving for a break. The fourth participant, the
PCC, stated that she preferred verbal communication, because it afforded her the
opportunity to make a one-to-one connection with a team member. All participants
agreed that they communicated with other team members throughout the shift, on an as-
needed basis.
What are some of the challenges within the nursing team that impact the ability to
communicate effectively in a collaborative practice environment? Responses offered by
participants to this question included the following themes:
1. Workload: Participants all acknowledged that when it was busy on the unit,
communication was not as effective as it could have been. They felt that increased
workload "tired out staff and made them "grouchy" and prone to "jumping to
conclusions," which negatively impacted their ability to communicate within a
team environment.
2. Acuity: Participants stated that a patient with increased acuity on the unit was a
challenge because it often meant that nursing staff were very busy, resulting in
nursing staff "communicating only what is necessary. . . . We just want to focus
and do our work by ourselves."
Do you communicate differently when you are communicating within your
nursing discipline (e.g., RN to RN) as compared to when you communicate with another
nursing discipline (e.g., RN to LPN)? If so, what is the difference? All participants agreed
that they communicated differently when they were communicating within their nursing
discipline as compared to communicating with another differently. Participants stated that
the difference was in the detail of the information communicated; they provided detail
"according to the skill level and education of the other team member." The RN
participant stated that she communicated information regarding a patient's physical
condition, medications, and treatments to anther RN and communicated information
regarding a patient's physical abilities (such as how the patient transfers from the bed to
the wheelchair) to the PCA.
Thinking of an example of poor communication between nursing team members,
what do you see as the contributing factors that made it poor communication? Responses
from participants were divided into two themes:
1. Nonverbal communication traits: Participants identified nonverbal communication
traits that negatively impacted communication, including angry facial expression,

loud tone of voice, closed body posture, not looking the other person in the eye,
and crowding (lack of personal space).
2. Disrespect: Participants said that disrespect between team members inhibited
effective communication. Examples of disrespect included one team member
interrupting and not waiting for another team member to finish a task, and a team
member demanding assistance rather than politely asking for help.
Thinking of an example of good communication between nursing team members,
what do you see as the contributing factors that made it good communication? All
participants identified trust as the major factor in facilitating effective communication.
When asked to define trust, one participant said it was the "chemistry between team
members." Another participant stated trust is "knowing that another team member has
your back."
What skills do team members need to communicate effectively? Participants
responded that team members need to speak in a respectful manner (not raise their voice),
listen, and clarify if something is not understood in order to communicate effectively.
What do you perceive are the barriers to facilitating effective communication
between nursing staff in a collaborative practice environment on an ACE unit?
Participant answers, when themed, included the following:
1. Acuity: Participants responded that when there was an increase in patient acuity
on the unit, team members were more focused on how they provided care to
patients individually, rather than communicating and collaborating with team
members and thereby optimizing of the skill set of each team member.
2. Workload: Participants felt that when the workload was heavy on the unit, they
did not have the time to communicate effectively; they did not have time to
communicate, which resulted in them each providing patient care individually,
rather than working as a team.
3. Change: Participants felt that some of the staff on the ACE unit were resistant to
change, and this resistance resulted in staff being unhappy at work and
"communicating with a negative attitude."
What do you perceive are the solutions to facilitating effective communication
Participants stated that having communication courses as part of any organizational
change initiative would be beneficial. All participants did not feel that mandating staff to
take communication courses each year was appropriate; however, staff having the
opportunity to take communication offered through the organization would be helpful.
One participant stated, "We're all professionals, and part of our professional
responsibility is to respectfully communicate with coworkers."
Study Conclusions
This research project identified five concluding themes, following an analysis of
the quantitative and qualitative data and a review of the literature. These conclusions
begin to answer the research question of how leaders can facilitate effective
communication between nursing staff (RN, LPN, PCA) in a collaborative team practice
environment on an ACE unit. In addition, insight into what factors contribute to the
current state of communication on the ACE unit and what factors contribute to effective
communication is provided. The five conclusions, which will be discussed further,
include the following:
1. Respect between nursing team members is a key factor in facilitating effective
communication;
2. Trust between nursing team members is a key factor in facilitating effective
communication;
3. Increased workload negatively impacts team members' ability to communicate
effectively;
4. Communication skills include the ability to listen, the ability to speak clearly and
concisely, and an awareness of nonverbal communication traits; and
5. Ongoing educational courses are seen as beneficial to facilitating effective
communication.
Respect
Exchanging meaningful information at times can be formidable, especially in the
constantly changing environment of health care. Effective communication is only
possible where there is mutual respect between team members (Fitzsimmons & White,
1997).
The need to be respected is universal among human beings (DeLellis & Sauer,
2004). Respect is defined as "esteem for or a sense of the worth or excellence of a person,
a personal quality or ability, or something considered as a manifestation of a personal
quality or ability" ("respect," 2007). Respect was identified as a key factor for facilitating
effective communication between team members by participants in the research focus
groups, although participants spoke more frequently on the negative impact of disrespect
as opposed to the positive impact of respect. One of the focus group RNs stated, "When I
am working with someone that I respect, I find that I am more comfortable talking to
them.... I share more with them.... I appreciate and value the skills that they bring to
the table.... We're a team."
Effective communication requires being present in the conversation, and by being
present in the conversation, the team member is demonstrating respect. Mutual respect
allows for the creation of a culture of support, and encourages positive nursing practice.
(Latham et al., 2008).
Trust
The key to good communication in a team is trust. When teams have high levels
of trust, the exchange of information is encouraged, team members are more willing to
become involved in the team's activities, and team members are more willing to commit
to the team's goals rather than focus on personal goals (Levi, 2007).
The research concluded that nursing staff on the ACE unit view trust as a key
factor in facilitating effective communication. Established trust within a team contributes
to effective communication by encouraging and enabling team members to share
information in a nonthreatening manner (Osterman & Kottkamp, 2004). When
communication is effective, team collaboration and quality of patient care are improved
(Coeling & Cukr, 2000). According to one of the LPNs, "When I trust my coworker, I
find it easy to share information with her . . . to talk through challenging patient situations
and problem solve."

Increased Workload
In today's challenging environment of health care, with ever-increasing demands
for service, the impact of increased workload is felt by nursing staff. Increased workload
results in numerous competing priorities for nursing staff time. As a result,
communication between team members is often poor and incomplete (Horwitz et al.,
2009).
Although over half the survey respondents commented that the work environment
of the ACE unit encourages open communication, when exploring communication
barriers with the focus group participants from the ACE units, they said their workload
has increased over the past several years. Participants stated that, due to the demands for
their time, they often feel that they are not fully prepared to communicate with their team
members; they may not have all the current relevant data on their patient or they may not
have had time to follow up with a patient regarding a specific concern. One focus group
participant commented, "When I'm busy, I just focus and do my work and don't have the
time to talk to other staff."
Communication Skills
Communication is one of the central activities of a team. Participants identified
listening, speaking clearly and concisely, and being aware of nonverbal communication
traits as three skills necessary for team members to have in order to communicate
effectively.
Listening is a vital communication skill. Listening well means that one team
member is paying attention to another team member and is engaged in the conversation.
Listening well ensures that information is understood by both team members,

acknowledge the importance of the message (Parker, 2008). Speaking in a clear and
concise manner is key, as the basic requirement of a message is that it be understood in
order to be effective. Messages that are too complex, or contain lots of jargon, are
ineffective (Levi, 2007).
Nonverbal communication accounts for 65% to 93% of communication.
Nonverbal communication conveys what the speaker may not be able to express and/or
may communicate something different from the actual words being said. This can result
in the listener losing confidence, faith, and trust in you as a team communicator (Gentry
& Kuhnert, 2007).
Ongoing Educational Courses
Ongoing education is an important component in the sustainment of effective
team communication. Ongoing education ensures ongoing skill competency, provides a
process for the maintenance of skill, reinforces the behaviour, and demonstrates
organizational commitment to staff (Bourne, 2007).
Focus group participants, while agreeing that the organization should offer
courses on communication and that having team members take ongoing education
courses in communication would positively influence the effectiveness of team
communication, differed in their opinions as to what the role of the organization was in
enabling staff to participate in these courses. One focus group member felt that the
organization should support staff by providing education leave and financial support;
another focus group member felt that it was the responsibility of individuals, as part of
their professional development, to decide whether or not to take ongoing education
courses.
Scope and Limitations of the Research
The focus of this project was how effective communication can be facilitated
between nursing team members in a CP environment, specifically on an ACE unit at
VGH. The data collection relied on voluntary participation from nursing team members
for the online survey and focus groups. There were a number of factors that limit the
application of the research findings. These factors include participants, number of focus
groups held, and the researcher.
Participants
Participants included RNs, LPNs, PCAs, and PCCs who were employed in the
ACE program at VGH, but did not include various other nursing disciplines in the ACE
program such as care management leaders, clinical educators, and clinical nurse
specialists. These disciplines communicate patient care information to RNs, LPNs and
PCAs on a daily basis. Therefore, the research conclusions may not be applicable to units
where there is a significant influence by specialty nursing disciplines such as those
mentioned above.
Additionally, on the ACE unit at VGH, the breakdown of nursing staff is RN
(50%), LPN (17%), and PCA (33%). The research conclusions may not be applicable to
units where there is a different staffing ratio.
Number of Focus Groups Held
The two focus groups that were held provided rich data. However, given the large
number of nursing staff on the unit (105 staff, of which 8 were focus group participants),
the participation rate for the focus groups could be considered poor. This potentially
limits the applicability of the findings to other units in the organization where CP is
implemented.
Researcher
I am a senior leader in the organization, a director of operations. I contacted staff
for participation in the research study through e-mail, and this may have influenced the
overall response rate. Additionally, I facilitated the focus group sessions, which may have
influenced participant responses to the focus group questions. I am also part of the
working group implementing CP in four programs in the organization this year. This may
have affected the interpretation of the data and therefore limited the value of this report.
Conclusion
This chapter provided a detailed description of the study findings made during the
action research project. It identified conclusions based on the study findings and
highlighted limitations to the research.
Chapter 5 will outline my recommendations for the ACE program and for the
organization of VGH. Implications for future research will also be highlighted.

CHAPTER 5: RESEARCH IMPLICATIONS
This chapter outlines four recommendations based on the conclusions discussed in
the preceding chapter. This chapter also discusses the organizational implications of
implementing these recommendations and explores implications for future research.
Recommendations
The recommendations are supported by study findings and the literature and
1. Establish effective communication between nursing team members as a priority
for the ACE program;
2. Make education on effective communication a part of all major change initiatives
implemented within the ACE program;
3. Establish a culture of trust and respect between nursing team members on the
ACE units; and
4. Assess the possibility of VGH creating a communication workshop specifically
for nursing staff who want to become nursing leaders on the ACE unit.
Recommendation 1: Establish Effective Communication Between Nursing Team Members
as a Priority for the ACE Program
In today's complex and fast-paced world of health care, in order to meet the ever-
increasing demands on the system, the inpatient units have changed in many ways. The
ACE units are currently operating at a capacity of 105%, medicine admissions are up
17.4% from last year, and there are constant staffing challenges (VCH, 2008). As a result,
many program and organizational initiatives have focused on improving patient flow and
recruitment of staff. Although these are important initiatives, the importance of effective
communication must not be overlooked. The survey participants identified that effective
communication was essential to providing safe patient care; therefore, I recommend
establishing effective team communication as a priority for the ACE program. By doing
so, the ACE program will see the benefit of increased collaboration, increased nurse
satisfaction, and improved quality of patient care (Coding & Cukr, 2000).
Communication within teams also is important. Teams create the "potential to
make better decisions because members can pool information from diverse backgrounds
and experiences" (Levi, 2007, p. 97). However, this benefit occurs only if a team member
shares information with other team members. In order to share, one must be able to
communicate. This has a huge potential to impact the ACE program positively, because
the nursing team consists of not only different nursing disciplines (RN, LPN, PC A), but
also team members with a variety of different work experience (other hospitals, other
nursing specialties), years of work experience, and cultural backgrounds. By establishing
effective communication as an ACE program priority, the richness and diversity of the
skills and experience of the nursing staff will be capitalized on, contributing positively to
team dynamics. As a study participant said, "Good communication makes us a better
team, which results in better patient care."
Leaders will be required to engage others in making effective communication a
priority. According to Kouzes and Posner (2002), there are five practices of leadership:
model the way, inspire a shared vision, challenge the process, enable other to act, and
encourage the heart. For the leadership team in the ACE program, modeling the way is
the most important for establishing effective communication as a priority for the
program, because in order for leaders to gain commitment to a goal and vision, they must
model the behaviour they expect of others. Kouzes and Posner stated, "Exemplary leaders
go first. They go first by setting the example through daily actions that demonstrate that
they are deeply committed to their beliefs" (2002, p. 14).
Recommendation 2: Make Education on Effective Communication a Part of all Major
Change Initiatives Implemented Within the ACE Program
Participants mentioned workload as a major contributing factor inhibiting
effective communication between team members on the ACE units. Increased workload
did not allow the nursing staff time to prepare to communicate or to use the
communication tools available on the unit (such as the nursing kardex or census sheet)
effectively. One reason noted in the study findings for increased workload was the
number of change initiatives implemented on the ACE unit each year. These change
initiatives range from minor (new bed linens, new dietary menus) to major (collaborative
practice, medication reconciliation).
Change is by nature a venture into uncharted waters, and it is impossible to
predict all the obstacles and challenges that may be encountered (Yukl, 2006), but
through effective communication, the negative impact of these obstacles and challenges
can be mitigated. Study participants suggested education courses related to
communication as one solution to help ACE staff improve their communication skills; I
would take that suggestion one step further and recommend that education courses be
part of any major change initiative implemented in the ACE program. Kitchen and Daly
(2002) noted that training in communication skills increases the success of the change
initiative, stating, "Communication does not just have a role in the management of
change, it has the role" (p. 52).

CP was a major change initiative implemented on the ACE unit. One of the tenets
of CP is that the team nursing model is used, rather than the primary care model (patient
care is the responsibility of the team, not an individual). Within the team, each nursing
discipline's scope of practice is maximized. RNs and LPNs each have their nursing
practice governed by their respective professional college, whereas PCAs are an
unregulated profession and therefore the provision of care by a PC A must be directed by
an RN or LPN. This has resulted in RNs and LPNs on the ACE units delegating nursing
tasks to PCAs. When CP was implemented on the ACE unit, RNs and LPNs experienced
difficulty delegating nursing tasks to another team member; they were not sure how to
delegate effectively and often ended up dictating tasks. This led to nursing team members
feeling frustrated and caused a breakdown in communication. Participants in the focus
groups confirmed that this was an issue on the ACE units.
One of the keys to successful delegation is communication. By having
communication courses as part of the CP orientation, the ACE nursing staff would have
had the opportunity to learn how to delegate tasks and receive delegated tasks.
Potentially, fewer breakdowns in communication would have occurred between nursing
team members during the implementation phase of CP. Study participants felt that the
opportunity to receive communication courses would ensure that their communication
skills were always "up to par," allow them the opportunity to learn and reinforce effective
communication techniques, and encourage them to embrace change in a positive manner.

Recommendation 3: Establish a Culture of Trust and Respect Between Nursing Team
Members on the ACE Units
The culture of a team, or group, is defined as its members' "shared assumptions
and beliefs about the world and their place in it, the nature of time and space, human
nature, and human relationships" (Yukl, 2006, p. 163). One of the major functions of
culture is to help the team understand the environment and determine how to respond to
it. This reduces anxiety, confusion, and uncertainty (Yukl).
My recommendation that a culture of trust and respect be developed between
ACE nursing team members is supported by the study findings. Study findings revealed
that trust and respect were two key factors contributing to effective communication
between nursing team members on the ACE units; trust between team members
facilitated effective communication, whereas disrespect between team members hindered
effective communication. Study participants noted that trust and respect needed to be
reciprocal between team members.
The opportunity for staff to participate in a team-building session, organized and
run by a skilled facilitator, would be the first step to creating a climate of trust and
respect. With CP, nursing teams on ACE are being formed with members from three
different nursing disciplines. These nursing teams are expected to work together to
achieve a common goal, but very little time is spent determining the core values of the
team. I recommend that developing core team values be a focal part of the initial team-
building session, because diverse value systems lead to difficulty in developing trust and
respect among team members (Webber, 2002). Follow-up team-building sessions could
be scheduled depending on the outcome of the initial session.

According to Henneman et al. (1995), collaboration flourishes in an atmosphere
where there is a high level of trust among the disciplines; team members can assume
accountability and responsibility for patient care more easily when trust and respect for
individual perspectives are part of the team's culture.
Recommendation 4: Assess the Possibility of VGH Creating a Communication Workshop
Specifically for Nursing Staff Who Want to Become Nursing Leaders on the ACE Unit
Currently in the ACE program, there is no formal training program for staff who
would like to take on frontline leadership roles such as PCCs. Although further research
and study is required, I recommend that VGH look at the possibility of creating a
communication workshop for these potential leadership candidates. I believe that we need
to nurture and support staff who want to embark on this leadership journey. One PCC
who participated in the focus group stated that she wished she had more knowledge of
effective communication techniques, because she found that she did not know how to
break through barriers when she had difficulty communication with staff.
Leaders can positively impact how staff work in a team environment through their
(the leaders) use of effective communication practices. Leaders can foster communication
through better listening, clear conversation, and respect for each other as individuals
(Wheatley, 2007). Communication skills can be developed through a variety of methods,
such as formal courses or simulations. These methods are more effective if VGH as an
organization supports a culture of learning. The department of Learning and
Development can be engaged to determine the feasibility of creating such a course or
possibly adapting an existing course to the specific needs of the ACE program.
More individual learning will occur if the organization has strong values for
personal development and lifelong education. However, VGH needs to provide more than
just learning opportunities; by making it easier for staff to attend education courses
through supporting staff to take time off work and providing education subsidies, the
organization will facilitate learning (Yukl, 2006).
Organizational Implications
As a result of the research undertaken at VGH, the organization has been provided
with four key recommendations. These four key recommendations provide VGH with the
opportunity to realize the benefits of effective nursing team communication on an ACE
unit. The results of this research study will be shared with staff of the ACE program and
senior leadership at VGH. Actions will include the following:
1. Presentation of the study findings at ACE program staff meetings, where the
study conclusions and recommendations will be emphasized. This will allow the
staff to participate and engage in further discussions of the recommendations.
2. Presentation of the study findings and recommendations to the senior leadership
team at VGH. It is essential that there is buy-in from the organization.
There are many organizational benefits, as outlined previously, to effective
communication. The ongoing support of senior leadership at VGH, as well as the
engagement of other departments such as Learning and Development, Professional
Practice, and Employee Engagement, will be vital to implement and sustain these
recommendations, because there are many competing priorities across the organization.
Organizational initiatives on ACE will need to be prioritized and implementation dates
planned out; which should assist in mitigating the impact of any initiative that is delayed
or deferred. If effective communication is not supported by the organization or made an
ACE a program priority, there is a risk that patient care could be compromised and the
implementation of new initiatives hampered, because a lack of effective communication
inhibits collaboration between team members and is linked to patient harm (Suter et al.,
2009).
Senior leadership must take responsibility to ensure that a common vision is
created so that everyone is working towards the same end (Strelioff, 2002). CP is an
initiative that is being implemented across the organization, on every in-patient unit, and
effective communication is a key component of successful CP. By supporting the
recommendations identified in this research study, the organization will realize the
benefits of CP on ACE, such as increased staff retention, staff productivity, staff morale,
and patient satisfaction and decreased overtime, sick time, and job vacancies. As CP is
rolled out to other in-patient units, having a positive experience to build from and an
encouraging story to tell will increased the chance of success implementation of CP on
other units.
The financial cost to the organization of implementing these four
recommendations, in addition to continuing the implementation of CP on a larger scale, is
minimal when weighed against the potential gains. It is recognized though, that in today's
current health care climate, there are many demands for scarce financial resources.
Upfront costs would be incurred as communication courses are developed, team-building
sessions facilitated, and nursing staff supported to attend these sessions through
opportunities such as education leave. Savings could be generated to offset the upfront
costs through the successful implementation of CP (increased staff retention and

productivity, decreased overtime, decreased sick time, decreased job vacancies, improved
patient care, and decreased length of stay) (Blegen & Vaughn, 1998; McKenna, 1995;
Needlemen et al., 2002a, 2002b). Ongoing education and team-building sessions, with
agreement from the organization, could be provided through the efforts of Learning and
Development, Professional Practice, and Employee Engagement.
The organizational implications of not proceeding with this research study's four
recommendations, and failing to support effective communication as a key pillar of CP,
are multiple. The ACE nursing staff would lose an opportunity to advance their own
learning, to build an effective, high-functioning team, and to improve patient care, which
would have increased not only their own sense of value, but their perception of how
deeply the organization values their contributions. VGH would miss an opportunity to
demonstrate its commitment to staff and patient satisfaction and to obtain pertinent and
relevant data related to the implementation of CP.
Implications for Future Research
This research study presented the perceptions and thoughts of a small number of
frontline staff and leaders from the ACE program at VGH. Study conclusions and
recommendations focused on the benefits of facilitating effective communication among
nursing team members in a CP environment. Through the action research process though,
several questions presented themselves and remained unanswered. Areas for future
research include, but are not limited to, the measurable impact of effective
communication on CP and the measurable impact of culture on CP

Measurable Impact of Effective Communication on CP
There are many established protocols, such as content analysis, that look at the
effect of communication. My research study provided some qualitative and quantitative
data on the effective of positive and negative communication on CP on the ACE unit at
VGH. However, VCH is a subset of VCH, and VCH is a large organization, with over
22,000 employees and 9,000 inpatient beds, and there is the opportunity to study how
leaders can facilitate effective communication in a CP environment across a broad
spectrum of units. What impact does the unit specialty (e.g., orthopaedics, cardiology,
respirology) have on effective communication? Do leaders in community facilities face
different challenges facilitating effective communication compared to leaders in a
hospital? RNs, LPNs, and PCAs each receive a different amount of postsecondary
education in order to practice—how does the amount of post secondary education affect
the ability of an individual to communicate effectively?
Measurable Impact of Culture on CP
Culture can be defined as the set of shared attitudes, values, goals, and practices
that characterize an organization or group ("culture," 2006). Due to the current and
forecasted nursing shortages, employees are being recruited from all over the world.
What is the impact of different ethnic cultures on effective communication? What are the
staffing characteristics of the various areas? Do generational differences between nursing
staff influence their perception of effective communication? How does organizational
culture and/or the culture of the specific nursing unit (consensual, rational,
developmental, and hierarchical) impact the ability to communicate effectively?

Conclusion
Chapter 5 presented the specific recommendations of this study.
Recommendations included establishing effective communication as a priority for the
ACE unit, making education on communication a part of all major organizational change
initiatives on the ACE unit, developing a culture of trust and respect among nursing team
members, and assessing the possibility of creating a communication workshop
specifically for ACE staff who wish to become unit leaders. The organizational
implications of implementing these recommendations and the consequences of not
implementing the recommendations were discussed. Areas for future research have been
identified. Chapter 6 will outline lessons learned through the research process.
CHAPTER 6: LESSONS LEARNED
For the last 6, almost 7 months, I have been engaged in the journey of an action
research project. This journey has been exciting, challenging, frustrating, exhausting, but
most importantly rewarding. As a result of this journey, I have learned lessons not only
about the research process but personal lessons as well.
Lessons Learned From the Research Process
The first lesson I learned was not to be afraid to take the time to be very specific
and focus the research question. The broad topic I wanted to research was
communication, but I struggled to narrow down the research question to a manageable
project scope. I found that I spent a lot of time, in the initial stage of writing the research
proposal, waffling back and forth as to what my research question was going to be. I
began to panic, as I heard that fellow learners had already submitted their project
proposals, which led me to start to try to base my research question on the data that I
thought I might collect. Finally I had the "aha" moment and realized that one of my
proposed subquestions was actually the main research question. By allowing myself this
time though, I ultimately ended up with a research question that I was happy with (which
is important because you become immersed in the topic), had a manageable scope, and
would be of benefit to the organization.
I was also concerned about conducting a research project in one of the programs
in my portfolio. While I was no longer involved in the day-to-day operations of the unit, I
felt that my position of authority within the organization could have influenced the
participation of staff. Staff may have felt obligated to participate in the research or been
cautious about the answers that they provided me. It was challenging to talk to staff about
the research project without creating the perception that their decision to participate in the
research project would influence my opinion of them.
When developing my survey and focus group questions, I engaged my research
advisory team in reviewing the questions and providing feedback and suggestions. This
was of enormous benefit, and it assured me that I was on the right track, asking the right
questions. I recommend that all future learners use a research advisory team.
I learned that it is important to be flexible and patient when conducting a research
project in an organization during work hours. Timelines can often be difficult to adhere
to, as crises and issues arise at work, and study participants may not be able to leave work
at the agreed upon time. Be prepared to readjust your research schedule. I had to
reschedule my focus groups for later dates due to staffing challenges that impeded the
ability of study participants to leave their work units.
A final lesson learned from the research process is that when conducting a
qualitative research project, the amount of data collected to be analyzed can be
overwhelming. A single focus group, held for 1 hour, can result in 50 pages of
transcribed data. I found it helpful to continuously review the data, because the more that
I read, the more the themes became apparent.
Personal Lessons Learned
Aside from the lessons learned from the research process, I gained insight into
myself as a learner and as a leader throughout this project. Throughout this research
project, there were many changes at work for me. Right before the start of the research
project, I took on a new role as director of operations, medicine. This was a big step for
me to take, and I found that the demands of this new role consumed most of my time. It
was easy for me to procrastinate and rationalize why I would start my research project
next week! This aligned nicely with my characteristic of being pressure prompted! I
struggled at the beginning, until I talked to other learners and graduates who had had
similar experiences and sought advice from them. Revising my project timeline to reflect
the demands of my new role, and booking time away from work to focus on the research
project, afforded me the ability to conduct this study.
The MALEAD program allowed me the opportunity to put theory into practice.
Transitioning into a new role as director, while stressful, was actually a benefit, as I was
able to incorporate much of my learning into practice. The program also gave me the
framework and foundation of leadership skills; I had previously found that while I felt I
intuitively knew what to do as a leader, I was missing the theory and rationale supporting
my actions.
Through the MALEAD program, I also discovered the importance of self-
reflection. Self-reflection has allowed me to better understand myself as a person and as a
leader and made my life experiences a rich source of learning. Through self-reflection, I
have thought a lot about my goals, both personal and career, and what motivates me to
achieve these goals. One goal is a passion for life-long learning, to continuously expand
my knowledge and thinking. While my journey at Royal Roads University is almost at an
end, I know that my next adventure is just around the corner, waiting for me to arrive.
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APPENDIX A: LETTER OF INVITATION TO PARTICIPATE IN SURVEY
[Date]
Dear [Prospective Participant],
I would like to invite you to be part of a research project that I am conducting.
This project is part of the requirement for a master's degree in leadership at Royal Roads
University. My name is Sharon Stapleton and my credentials with Royal Roads
University can be established by calling Stan Amaladas, acting director of the School
of Leadership Studies at [telephone number].
The part of the research will consist of an online survey and is foreseen to take
less than 15 minutes to complete. The survey can be accessed at [URL]. The questions
will refer to your experiences and thoughts as a frontline professional on the topic of
team communication in the Acute Care for Elders unit. This project is sponsored by the
Vancouver Coastal Health Authority.
The information you provide will be summarized, in anonymous format, in the
body of the final report. At no time will any specific comments be attributed to any
individual unless specific agreement has been obtained beforehand. All documentation
will be kept strictly confidential. Please note that the online survey company is based in
the United States; therefore all data are stored in the United States and subject to the
Patriot Act. Please feel free to contact me at any time should you have additional
questions regarding the project and its outcomes.
In addition to submitting my final report to Royal Roads University in partial
fulfillment for a master's degree in leadership, I will be sharing my research findings

with the Vancouver Coastal Health Authority. I may also choose to publish the findings
of my research in respective nursing or health care administration journals.
A copy of the final report will be published. A copy will be housed at Royal
Roads University, available online through UMI/Proquest and the Theses Canada portal,
and publicly accessible. Access and distribution will be unrestricted.
Given that I work in a supervisory capacity in my professional role at Vancouver
Acute, I assure you that your opinions, thoughts, feelings, concerns, and past experiences
shared during the focus group session will not affect our professional relationship or your
current employment status.
You are not compelled to participate in this research project. If you do choose to
participate, you are free to withdraw at any time without prejudice. Similarly, if you
choose not to participate in this research project, this information will also be maintained
in confidence.
Your completion of this survey will constitute your informed consent.
Sincerely,
Sharon Stapleton
APPENDIX B: INFORMED CONSENT AND CONFIDENTIALITY FORM FOR
SURVEY
Dear Participant,
This question constitutes an agreement to participate in my research project,
which it titled Effective Team Communication in a Collaborative Practice Nursing
Environment. The objective is to answer the research question, "How can leaders
facilitate effective communication between nursing staff (RN, LPN, PCA) in a
collaborative team practice environment on an Acute Care for Elders unit?" This project
is sponsored by the Vancouver Coastal Health Authority.
The information you provide will be summarized, in anonymous format, in the
body of the final report. At no time will any specific comments be attributed to any
individual unless specific agreement has been obtained beforehand. All documentation
will be kept strictly confidential. Please note that the online survey company is based in
the United States; therefore, all data are stored in the United States and subject to the
Patriot Act.
participate, you are free to withdraw at any time without prejudice. Simply exit the online
survey by closing the browser window.
Your completion of this survey will constitute your informed consent.
Do you wish to proceed? Yes or No.

APPENDIX C: SURVEY QUESTIONS
1. What is your job title? (check one):
RN LPN PCA Educator Patient Care Coordinator
Other
2. How many years experience in nursing do you have? (check one):
Less than 1 year 1-2 years 2-5 years 5-10 years
10-20 years Over 20 years
3. How many years experience do you have working on the Acute Care for Elders unit?
(check one):
Less than 1 year 1-2 years 2-5 years 5-10 years
4. What is your age? (check one):
Under 25 25-29 30-34 35-39 40-44
Over 45
5. How much do you agree with the following statements?:
Strongly Agree Disagree Strongly
Agree Disagree
a. The workplace environment

• • • •
facilitates open communication.
b. Unit leadership encourages open

• • • •
communication.
c. Effective communication is
• • • •
essential to providing safe
patient care.
d. During my shift, enough

• • • •
information is communicated to
me from other team members to
provide safe patient care.
e. At shift change, enough

• • • •
information is communicated to
me from other team members to
provide safe patient care.
f. I have the necessary skills to

• • • •
communicate effectively with
team members.
g. Team members have the

• • • •
necessary skills to communicate
effectively with me.
h. I have the necessary skills to

• • • •
communicate effectively with
unit leadership.
i. Unit leadership has the

• • • •
necessary skills to communicate
effectively with nursing staff.

APPENDIX D: FOCUS GROUP QUESTIONS
1. What one word would you use to describe the current state of team communication
between nursing staff on the ACE unit?
2. When you prepare to communicate information, such as patient care information,
with your team members, what steps to you take?
3. How often do you communicate with your team members during a shift? Are these
times preset?
4. What are some of the problems or challenges within the nursing team that impact the
ability to communicate effectively in a collaborative practice environment?
5. Do you communicate differently when you are communicating within your nursing
discipline (e.g., RN to RN) as compared to when you communicate with another
nursing discipline (e.g., RN to LPN)? If so, what are the differences?
6. Thinking of an example of poor communication between nursing team members,
what do you see as the contributing factors that made it poor communication?
7. Thinking of an example of good communication between nursing team members,
what do you see as the contributing factors that made it good communication?
8. What skills do team members need to communicate effectively?
9. What do you perceive are the barriers to facilitating effective communication between
nursing staff in a collaborative practice environment on an ACE unit?
10. What do you perceive are the solutions to facilitating effective communication
11. Is there any other information that you would like to add?
APPENDIX E: LETTER OF INVITATION FOR FOCUS GROUP
[Date]
Dear [Prospective Participant],
I would like to invite you to be part of a research project that I am conducting.
This project is part of the requirement for a master's degree in leadership at Royal Roads
University. My name is Sharon Stapleton and my credentials with Royal Roads
University can be established by calling Stan Amaladas, acting director of the School
of Leadership Studies at [telephone number].
The objective of my research project is to answer the following research question:
How can leaders facilitate effective communication between nursing staff (RN, LPN,
PCA) in a collaborative team practice environment in an Acute Care for Elders unit? This
project is sponsored by the Vancouver Coastal Health Authority.
fulfillment for a master's degree in leadership, I will be sharing my research findings
of my research in respective nursing or health care administration journals.
My research project will consist of two focus group sessions. Both focus groups
will be comprised of a variety of staff members from ACE nursing units at Vancouver
General Hospital. A variety of closed- and open-ended questions regarding team
communication and collaborative nursing practice will be posed to the focus group
participants. The focus groups will last for of 90 minutes. The foreseen questions will

1. What one word would you use to describe the current state of communication
between nursing staff on an ACE unit?
2. Please describe an example of good communication between nursing team
members and what you see as the contributing factors that made it good
communication.
3. Please describe an example of poor communication between nursing team
members and what you see as the contributing factors that made it poor
communication.
4. What are the perceived barriers and solutions to facilitating effective
communication between nursing staff on an ACE unit?
Your name was chosen as a prospective participant because you are currently
working on an ACE unit selected for this research project.
Information will be recorded in hand-written and audio-recorded format and,
where appropriate, summarized, in anonymous format, in the body of the final report. At
no time will any specific comments be attributed to any individual unless specific
agreement has been obtained beforehand. All documentation will be kept strictly
confidential through the use of a coding system to identify research participants. Due to
the nature of the focus group sessions, anonymity cannot be guaranteed.
and publicly accessible. Access and distribution will be unrestricted. All hand-written and
audio-recorded data collected during the focus group sessions will be destroyed 6 months
past publication of my thesis.

Please feel free to contact me at any time should you have additional questions
regarding the project and its outcomes. Should you choose to participate in this study, I
will invite you to a 45-minute debriefing session in which the research findings will be
presented.
Acute, I assure you that your opinions, thoughts, feelings, concerns, and past experience
shared during the focus group session will not affect our professional relationship or your
current employment status.
participate, you are free to withdraw at any time without prejudice. Similarly, if you
choose not to participate in this research project, this information will also be maintained
in confidence.
If you would like to participate in my research project, please contact me:
Name: Sharon Stapleton
Email: [e-mail address]
Telephone: [telephone number]
Sincerely,
Sharon Stapleton
APPENDIX F: INFORMED CONSENT AND CONFIDENTIALITY FORM FOR
FOCUS GROUP
[Date]
My name is Sharon Stapleton, and this research project is part of the requirement
for a master's degree in leadership at Royal Roads University. My credentials with Royal
Roads University can be established by telephoning Stan Amaladas, acting director of
the School of Leadership Studies at [telephone number].
This document constitutes an agreement to participate in my research project,
which it titled Effective Team Communication in a Collaborative Practice Nursing
Environment. The objective is to answer the research question, "How can leaders
facilitate effective communication between nursing staff (RN, LPN, PCA) in a
collaborative team practice environment on an Acute Care for Elders unit?" This project
is sponsored by the Vancouver Coastal Health Authority.
My research project will consist of two focus group sessions. Both focus groups
will be comprised of a variety of staff members from ACE nursing units at Vancouver
General Hospital. A variety of closed and open-ended questions regarding team
communication and collaborative nursing practice will be posed to the focus group
participants. The focus groups will last for 90 minutes. The foreseen questions will
1. What one word would you use to describe the current state of communication
between nursing staff on an ACE unit?
2. Please describe an example of good communication between nursing team
members and what you see as the contributing factors that made it good
communication.
3. Please describe an example of poor communication between nursing team
members and what you see as the contributing factors that made it poor
communication.
4. What are the perceived barriers and solutions to facilitating effective
communication between nursing staff on an ACE unit?
Information will be recorded in hand-written and audio-recorded format and,
where appropriate, summarized in anonymous format in the body of the final report. At
no time will any specific comments be attributed to any individual unless specific
agreement has been obtained beforehand. All documentation will be kept strictly
confidential through the use of a coding system to identify research participants. Due to
the nature of the focus group sessions, anonymity cannot be guaranteed. Research data
will be accessed by me and my research team, all of whom have signed confidentiality
agreements.
fulfillment for a master's degree in leadership, I will also be sharing my research findings
of my research in nursing or health care administration journals.
and be publicly accessible. Access and distribution will be unrestricted. All hand-written
and audio-recorded data collected during the focus group sessions will be destroyed 6
months past publication of my thesis.

General Hospital, I want to assure you that your opinions, thoughts, feelings, concerns
and past experiences shared during the focus group session will not affect our
professional relationship or your current employment status.
participate, you are free to withdraw at any time without prejudice, and any research data
obtained will be removed and not used in any data analysis. If you choose not to
participate in this research project, this information will also be maintained in confidence.
Please feel free to ask me questions at any time about my research project.
By signing this letter, you give free and informed consent to participate in this project.
Name: (Please Print):
Signed:
Date:
Witness:
APPENDIX G: CONFIDENTIALITY AGREEMENT
[Date]
I, , agree to maintain confidential all information discussed
during the focus group sessions in which I have been asked by Sharon Stapleton to fulfill
the role of observer and/or scribe as a support to her research study performed in partial
fulfillment for a master's degree in leadership through Royal Roads University.
I acknowledge that I have read and will adhere to the above terms and conditions
prior to participating in Sharon Stapleton's research study.
Signature of Observer/Scribe:
Witness:
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EFFECTIVE TEAM COMMUNICATION IN A

COLLABORATIVE PRACTICENURSING ENVIRONMENT

BSN, Ryerson University, 1990

A thesis submitted in partial fulfillment of

the requirements for the degree of

We accept this thesis as conforming

to the required standard

Laurie Leith, MA, Project Sponsor

Pamela Aikman, MALT, Faculty Supervisor

Stan Amaladas, PhD, Committee Chair

ROYAL ROADS UNIVERSITY

© 2009 Sharon Stapleton

The author retains copyright L'auteur conserve la propriete du droit d'auteur

In compliance with the Canadian Conformement a la loi canadienne sur la

care aides) in a collaborative practice team environment on an Acute Care for

communication, and suggested strategies leaders could use to facilitate effective

communication practices. Qualitative and quantitative research methods,

effective communication between nursing team members. Recommendations

included establishing effective communication as a priority for the ACE program,

incorporating communication courses as part of any major change initiative

the program between nursing team members.

I would like to acknowledge and express my sincere appreciation to Vancouver

knowledge, and experience, assisted me in completing my research project.

To Pamela Aikman, my faculty supervisor, and Laurie Leith, my organizational

have completed this journey without you.

Appendix H: Survey Responses by Nursing Discipline 90

Figure 1. Respondents' number of years of work experience 40

Table 1. Responses to Survey Questions 41

CHAPTER 1: FOCUS AND FRAMING

Today's health care environment is challenging, fast paced, and demanding.

the person, then the plan (Kouzes & Posner, 2002).

many changes. As acting director of operations, medicine at Vancouver General Hospital

responsibilities is assessing and implementing strategies to help mitigate current and

(2007) has forecast a 39% shortfall of RNs by 2015.

One organizational initiative implemented at VGH and designed to help reduce

Although much research has focused on nurse-physician communication,

effective nursing team communication is a vital aspect of a positive nursing practice

I also explored these subquestions:

1. What is the current state of team communication on the unit?

2. What communication skills are needed for effective collaborative team

As a leader, I was keen to be involved in a research endeavour that would,

According to Ritter-Teitel (2002), the most intensive communication is between

from an individual, autonomous working environment to an effective, high-functioning,

Significance of the Opportunity

practice (Vancouver Coastal Health [VCH], 2007).

opportunity to use a process that is "based on collaborative problem solving . . . between

of action" (2007, p. 10). As previously identified, one of the challenges of implementing

solving and re-education.

the principles of effective communication and potential strategies to increase effective

sick time, and job vacancies.

Systems Analysis of the Opportunity

were needed (Canadian Nurses Association & Canadian Association of Schools of

could increase the quality and quantity of services provided.

Through its Nursing Directorate, a department created in 2001 to address nursing

Ministry of Health, 2008).

entered into a partnership in the creation of a document outlining practice expectations

their complementary yet differing roles (College of Registered Nurses of British

Columbia Nurses' Union, College of Licensed Practical Nurses, Hospital Employees'

when health care providers developed specific competence in communication, then

of others and foster mutual trust.

VCH (2007) serves approximately 25% of British Columbia's population. It has

providing over 2.9 million patient days of care annually.

VCH's (2007) vision is of being "committed to supporting healthy lives in healthy

and physician resources through investments in training, working conditions, and