Building Effective Working Relationships among Academics through Participation in Communities of Practice

*Adeola Folasade Akinyemi, Vuyisile Nkonki, Lulekwa Sweet-Lily Baleni and Florence Rutendo Mudehwe-Gonhovi*

## **Abstract**

This chapter addresses the significance and importance of communities of practice in the professional development of academics as university teachers. Its documents the role of communities of practice in enabling and enhancing the development of a professional knowledge base, the acquisition of skills, and competencies for effective teaching practice, as well as the dissemination of practical knowledge needed within a community of teaching practitioners. It provides details of how a community of practice comes into being, and how working relations within a community of practice are fostered. There is an elaboration on how members of a community of practice come to perceive their substantive issues the same way, and how a common agenda is formed around those issues. It also discusses peculiar ways of dealing with the identified issues, and the manner in which expertise, resources, resourcefulness and experiences are exchanged and shared with improvement, change and further development of academics' teaching practices in sight.

**Keywords:** communities of practice, collaboration, mutual engagement, participation, problem solving, commitment

#### **1. Introduction**

Communities of practice (CoP) are group of people who share a common concern, a set of problems, or an interest in a topic and who through joint efforts fulfil both individual and group goals. Building effective working relationships among academics through their participation in communities of practice is very important as ways of collaborating, sharing ideas, mutual engagements as well as knowledge sharing. Good working relationships among colleagues in an organisation help to achieve the aims and objectives as well as promoting good outcomes among members of the organisation. This chapter will be on communities of practice and how to build effective working relationships among academics through their participation. The types of

communities of practice existing among universities' lecturers, especially towards maintaining effective working relationships will be considered. Also, social learning theory which primarily focused on theorising the concept of community of practice will be considered as part of the scope of this chapter. The activities the academics engaged in such communities of practice and how such activities are carried out will also form the scope of this chapter. In addition, why focus on communities of practice among academics as well as relevance of communities of practice to their professional development will also be considered.

#### **2. Communities of practice**

The CoP are expedient ways of building working relationships among academics as university teachers. Building effective working relationships can only be achievable through commitment, engagement, mutual understanding, interactions, collaborations, willingness to participate and contribute, and the determination to assist others for the sake of their professional development. CoP may exist among academics within the same department or other departments in the same university. Sometimes, CoP could extend to other universities where academics from various departments in different universities relate and collaborate as groups. The common adage that says "a tree cannot make a forest", is so true and real when it comes to CoP. People must come together as a group and before such group can evolve, they must have aims and objectives to achieve. Creating such a group must be purposive, vision and mission driven. Such a group should operate informed by the guiding rules and principles for actions of group members. Hence, CoP are imperative, purposive and cannot just be accidental.

As a model of professional development, CoP is an approach to teachers' professional development which enable academics to learn from and with their colleagues within their universities' communities [1]. The concept of CoP dates back to early 1990s. [2] in their work draw from the situated learning. Situated learning came into light as a result of learning among practitioners which take place in social relationships in their workplace instead of classroom. [2] view this concept as fostering interactions among workers which is inclusive of workers that are experts and trainees. It involves forming and norming which is necessary for the process of creating professional identity for trainees. The forming stage is the initial stage of putting the group together. At this stage, each member learns about their group needs, expectations and challenges. The norming stage is the phase where the team actually starts to function and work as a team. At this stage, members begin to understand each other's work practices and ethic. Group members' roles and responsibilities are clearly defined at this stage, rules guiding the members are defined, expectations from the members are set and teamwork begin among group members. In the interactions, experts serve as professionals who are consulted by new members and offer them professional advices. Through such interactions, problems were identified, experts learn more while new members also became experts through professional support offered to them. Few years later, Wenger developed on the situated learning through an empirical study of one insurance firm where Etienne focused primarily on theorising the concept of community of practice [3]. The key premise of his theoretical work is that CoP can arise in any domain of human endeavour, or organisation. This speaks to the wider scope of application of CoP as a framework that informs, frames, and focuses on professional development activities in different organisations, including educational settings.

It is also expected that universities' lecturers who have experience should build strong CoP where they will groom young graduates who have passion for research and teaching especially those who are willingly to go into teaching profession in

#### *Building Effective Working Relationships among Academics through Participation… DOI: http://dx.doi.org/10.5772/intechopen.95449*

higher education institutions. The willingness to embark on this journey of professional development is critical for the success of a CoP. Once practitioners are willing to do so, then support from senior colleagues in terms of collaboration and mutual engagement is highly recommended. [4] in their study on collaboration and mutual support as processes established by CoP to improve continuing professional teachers' development claim that effective participation of teachers in CoP is key to having mutual relationships among members through engagement in collaborative learning activities. This implies that teachers are expected to be active members in CoP, and participation is key to forge mutual relationships among group members by engaging in collaborative learning activities for their professional development.

CoP are groups of people who share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise in this area by interacting on an on-going basis [5]. The people involved must identify a problem, have passion for the tasks involved and must be experts in that area. One thing that is peculiar with CoP is that, the communities occur when a group of people who have desire to achieve certain things come together, interact and jointly work together to achieve their goals. Thus, CoP can occur anywhere, in a school, university, college or in an organisation. [6] note that CoP are groups of persons who have concerns or desire for certain things they engaged with and they show willingness to learn how to improve on it by interacting often with their group members.

Learning within CoP involves three essential processes, namely:


*Mutual engagement* among members of the CoP help them to know each other sufficiently well and interact productively among themselves. This also helps them to build trust among themselves, making them comfortable addressing real problems together and communicating with truth. Members also give and receive helping hands within the communities of practice. Hence, learning within a community of practice happens as a result of that community and its interactions.

*Understanding and tuning enterprise* indicates the level of learning energy among members of the community. Members share and have a common mission or objectives which are expected to be achieved. It demonstrates how much effort the community puts in keeping the learning at the centre of its initiative. Thus, the community must show leadership in pushing for development as well as maintaining a spirit of inquiry. They need to recognise and address gaps in its knowledge as well as remain open to emergent directions and opportunities.

*Developing repertoire, styles and discourses* shows the extent of self-awareness within the community. Members have a shared set of routines or principles of doing things which they have adopted as part of their practice. This shows how self-aware the community is about the selection, i.e. developing and its effects on practice.

#### **2.1 What communities of practice look like?**

In CoP, there are different activities taking place, these especially depend on the nature and purpose of such community. **Table 1** below gives a clear picture of what CoP look like depending on the educational functions that they are meant to serve.

**Table 1** below shows that different functions served by CoPs. Different scholars and in different organisations [4] use different names for CoPs. The different names


**Table 1.**

*Practices and different activities taking place in communities of practice.*

are learning networks, teacher clusters, teacher networks, professional and affiliation networks, learning team model, workplace learning, collaborative teacher research, thematic groups, or tech clubs, networked learning communities and collaborative practices [1, 6–9].

#### **2.2 Benefits of communities of practice**

Participating in a CoP should have an impact in academics' professional development, as group members and as individuals. The benefits of communities of practice according to [10–17] are as follows:


everyday problems, new tools, ideas and developments in their fields, things that are working out fine and those that are not working perfectly.


#### **2.3 Types of communities of practice**

CoP is seen as an essential model that enhances professional development. There are different types of CoP and these depend on the nature and purpose of such CoP. [3] argues that CoP are present everywhere and different kind of people are part of such community. The CoP could be at place of work, high school, university, college, home, civic or leisure places. Different activities and engagements are meant to take place in such community, however, group members have their objectives to be achieved. For instance, CoP among university lecturers are meant to promote professional development such that professional assistance and support are rendered to group members through mutual engagements, collaborations and interactions. According to [5, 18], the different types of CoP are:


In order to have a clearer picture and comprehensive types of CoP and detailed activities in each type of CoP, [19] highlight different types of CoP based on structural features of CoP. The structural features of CoP are categorised into four categories namely:


#### *2.3.1 Demographic category*

Under demographic category, three types of CoP are recognised as:


#### *2.3.2 Organisational category*

The following three types of CoP are listed under organisational category:


#### *2.3.3 Individual category*

The following two types of CoP are identified under this category

*Building Effective Working Relationships among Academics through Participation… DOI: http://dx.doi.org/10.5772/intechopen.95449*


#### *2.3.4 Technological category*

In technological category, most CoP now meet virtually because of moving towards digital age and most organisations depend on the use of technology of different forms. Virtual CoP is an advantageous for member to meet irrespective of distance barriers unlike in face to face CoP.

#### **3. Building effective working relationships among academics in communities of practice**

Good working relationships are essential for production and collaborations among academics. Many times people struggle with their challenges and shortcomings in their own silos. [3] contends that CoP result in three structural elements, which are mutual engagement, joint enterprise and shared repertoire. These elements usually result in one having a sense of belonging and participation by members vary from individual to individual [5]. Sharing ideas allows for reflection, better understanding, better navigation of knowledge, creation of new knowledge and ideas, and creates confidence among participants [20]. They argue that dialogic negotiations of knowledge can result in friendships being created over time. However, constructive negotiations in CoP have nothing to do with friendship but rather common interest and goals [3].

CoP can either be formal or informal [2] and in both instances there is need for engagement and collaboration [3]. Research has shown that learning often takes place in non-formal situations through interaction as they share experiences and ideas [21]. CoP generate trust and positive working relationships, because group members have sense of belonging, which enable professional development among group members [22]. Trust is a key element for engagement and productivity. Without trust it is difficult for academics to engage in productive dialogue, be at liberty to share their knowledge and expertise, it is difficult for one to be vulnerable in an environment where they do not trust the people they are expected to engage with. According to Poultney [23], due to the trust that CoP generate, it is easier for participants to connect and collaborate resulting in effective professional development for academics. Research has shown that positive working relationships give participants a sense of belonging [24] and as a result take ownership and responsibility for their development [25]. Sense of belonging and ownership create positive energy among the academics and their desire for all to develop encourages collaboration and engagement. A positive environment allows participants to share their expertise, share their experiences without fear of prejudice or being judged,

allowing for positive criticism from team members thereby resulting in continuous development and shorter times of task completion.

Tips for creating successful CoP as suggested by [26] are;


It can, therefore, be concluded that it is important to create and sustain positive working relationships in CoP for effectiveness, networking, sharing of ideas and positive change. CoP allow members to work in flexible and informal environments where everyone is a potential knowledge contributor.

## **4. Wenger social learning theory**

Social learning is routinely conflated with various thoughts, between the thought itself and its potential outcomes. This nonattendance of sensible clearness has limited our capacity to assess whether social learning has occurred and given that this is valid, what kind of acknowledging has happened, how much, between whom, when, and how [27]. [27] argue that to be seen as social learning, a cycle must:


A clearer picture of what these researchers mean by social learning is that learning must take place through interactions with others within the same group by utilising the social learning hypothesis by [3].

The initial work of [2] was the stepping stone for [3] social theory of learning on CoP which tested long-standing thoughts about learning. Specifically, they contended that learning is not an individual effort but a social cycle that is arranged in a social organised setting. A vital reason of his hypothetical work is that CoP can emerge in

#### *Building Effective Working Relationships among Academics through Participation… DOI: http://dx.doi.org/10.5772/intechopen.95449*

any space of human undertaking, as long as people share a common personality in their school of thought. As such, learning happens in various social practices through support in shaping the development of a bigger project some time. Etienne's investigation of learning in settings other than formal instructive settings can help a large number of us working in education to think differently about learning.

The four main premises of social learning by [28] are:


As Wenger puts it, CoP develop in stages and phases such as formation, integration and transformation [5]. Learning develops through active participation in the different stages.

Wenger's framework is used to address complex 21st century learning [29]. The theory centres around the vital worth made by social learning, recognising the sorts of significant values, flowing a model learning. The recognised values are the direct value, potential value, applied value, realised value, enabled value, and transformative value. Wenger's work is adopted from education with a view to professionalise teachers. The body of knowledge is much more alive, which is the community being engaging with the practice and hopefully to engage with each on what the practice is and what good practice is and what not good practice is and so forth. In a social theory of learning, CoP contemplate that learning takes place in a social setting and demands both participation and reification for meaningful learning.

The traditional approach to learning is described as a vertical view of learn¬ing where somebody assumes that one person knows and that information is passed to somebody who does not know [30, 31]. Social learning is the horizontal view of learning assumes that you and I are in a partnership and we negotiate what is it that we know is and how we understand it in our own contexts.

In this theory, learning occurs in cycles and starts in conversations, designs, problem solving, bench-marking and many more. Social learning should generate different types of values that describe a specific cycle [32] like engaging as learning partners in debating, creating a document together, going to a field trip together. Immediately you get to know each other and a person understands you, have fun, one feels inspired. This is the first cycle of learning and value one gets from just participating, called immediate value. Immediate value generates from enjoying to be in each other's company, producing great ideas and inspirations and forming new connections and collaborations among each other. The main idea or activity will be producing a particular purpose. In the quality of the conversation among stakeholders, sharing different world views, different angles of solving a problem, and creating networks, produce a potential value. The potential value is a second cycle of learning which may or may not end up profiting participants.

Learning does not end with the potential value in the theory by Wenger, but proceeds to the trying of the feedbacks you receive from the gathering as the third cycle termed applied value. In this cycle one learns when going back into the organisation and applying the new ideas, follow-up in connections and do a new project together. The cycle is accompanied by the change in practice as the result of the learning partnership activity. In a way people create multiple opportunities of learning. The creative nature of the CoP is when participants put acquired knowledge into practice. Creativity involves re-learning and generation of new knowledge leading to the fourth cycle of the realised value. One can see the changes in an institution.

Whether the implementation of new knowledge is a success or a failure one needs to have feedback loops because it is important for further learning. The feedback develops the learning loops to make learning relevant, adaptive and dynamic. A project Support team and community leadership roles are crucial in the learning process because activities such as logistic preparation, facilities, technology, and agenda design to mention a few need to be considered. It is the key aspect of the learning process to develop the implementation strategy. To acknowledge the strategic value, the nature of the vital discussions is the fundamental piece of social learning among the partners and permit them to accommodate their exercises into the master plan. This is called the enabling value. Notwithstanding, learning is not being restricted to an improvement and execution, it can likewise create new points of view or new meanings of achievement, and it can much trigger more extensive social and institutional changes, named transformative value or reframing value [32]. The transformative value or last cycle is the most dramatic aspect of learning.

As such it is significant that every one of these pieces ought to be set up and there should be a unique stream among them for figuring out how to have any kind of effect in this day and age. The value creating cycles makes one to be aware of where to focus attention. Setting of goals before you start a project with partners and choosing what conditions to follow, should be set up. The framework can also be used to evaluate the project and follow indicators to each cycle. Embedding social learning in the project is a strategic imperative. This is not only meant for students but also CoP in terms of academic staff development. The last cycle dimension takes the assumptions of where world ought to be in applying the flexible process in the ever-changing world operations especially in the academic environment. Therefore, social learning theory on communities of practice are bothered about learning in having the effect in the quickly evolving world, the principles of the gamechanging: science is changing, innovation is changing, and international affairs is evolving. In reality, things are excessively powerful and complex.

#### **5. Different activities academics undertake in communities of practice**

CoP are described with three measurements [3], namely:


#### *Building Effective Working Relationships among Academics through Participation… DOI: http://dx.doi.org/10.5772/intechopen.95449*

Right now, there is huge, contending pressures for transformation in higher education. Numerous scholars decide to change pedagogy and curriculum mirroring pedagogical research together with supportive learning and collaboration. A few changes, be that as it may, are forced by institutional approaches reacting to the more extensive higher education setting [33]. CoP may assist educators to revise their tasks at hand and diminishing open doors for communitarianism dynamic enhancing professional skills development with common commitment as the fundamental purpose within their various communities. [33] investigation on educational program change is an example of revising tasks at hand and focus on professional development by using an integrated method to course design and supportive learning. Also, educators engaged in a joint venture to revise the curriculum plus the significant alterations in university policy. CoP model promise the accomplishment of educational objectives by tending to instructors' necessities, as opposed to just raising requests on staff, to fortify commitment, joint efforts, assemble abilities and offer accepted procedures.

Mutual engagement is evident in [34] who note that globally, high schools have seen themselves faced with changes relating to changing educational program systems, new plans for teacher capacitation and empowerment together with their shifting roles. In reality, changes that underlie the expansion of combined activity between instructors incorporate collective teaching, soundness between subjects, and circulated decision making. These changes call for meeting and coordination between teachers to manage late changes and the going with multifaceted nature of work and continuous cooperation.

On a similar note, engagement in higher education, schools and districts that are associations in their privilege yet face expanding information challenges [6] is necessary. CoP hold the guarantee of empowering associations among individuals over these conventional structures to defeat considerable hierarchical issues. Another examination directed in [35] express that a topographically scattered yet disciplinarily affectionate community can work as a steady, non-various levelled CoP depending on the extent of mentorship, plus the creation of social resources. These scholars state that the most important imperative is to have one committed person to drive meetings and cycles of the CoP via Skype or email in a synchronous or asynchronous learning environment. It is also essential to analyse the organisation in CoP terms to gain better insight into its development, to distinguish its qualities and shortcomings, and to guarantee its continuation and shared collection.

The primary importance of CoP is for teacher preparation and breaking barriers between managers and subordinates [6]. For example, there is mutual engagement among staff members in the development of manuals and publications that were absent in their profession [6]. This gathering of auditors in the public sector was from various nations in Eastern Europe and Central Asia to shared work, stories, and relics made over the seven years of their endurance time giving a feeling of coherence and reason. There was no segregation of participants based on their seniority levels because of the CoP model used. Meaning, the CoP promotes lifelong learning within the organisation to fulfil the common institutional goals and initiatives.

A joint undertaking is another significant movement for academics in CoP. A variety of researchers and reformers has required the reinforcing of coordinated effort between instructors by methods for advancing networks of teachers in schools [34]. The action requests that foundation chiefs should convey the command to continue or create networks of training in their orders considering variety contemplations regarding instructive level, residency, word related insight, and gender in the arrangement of teacher groups for creating organised responsibility on accomplishing learning results. Notwithstanding sorting out different groups,

school pioneers could expand teachers' joint duty and responsibility for undertakings and group execution. The joint venture in administration, for example, choices are not made by a solitary individual; rather, choices arise out of collective exchanges between numerous people, occupied with commonly subordinate exercises. [36] converses with the school-based insight and the joint endeavour that scholastics could take part in. CoP can drive methodology, create new lines of business, take care of issues, advance the spread of best practices, build up individuals' expert aptitudes, and assist organisations with selecting and holding ability [11].

The joint venture can be experience in community projects are also activities academics can create solid associations with guardians and communities implies another method of working for governments, for administration organisations, and teachers [37]. For instance, in Thailand, such CoP resulted in upgrading of educational programs, employing volunteer teachers for co-curricular exercises, and raising funds for assets [37] in adjusted congruity. It is the kind of CoP model that administrations can advance through preparing, consolation and backing, yet in addition to stretch out the result of gathering pledges and upkeep and development of structures. Thus, CoP in schools enhances opportunities of collaboration among staff in implementing changes to educational programs, new plans for teacher professional development and to the instructors' functions. The collaborative effort deepens understanding in teachers' responsibilities. Therefore, there is shared collection of responsibilities between instructors by implanting coordinated effort into the school culture.

The idea of collaboration of academics from various disci¬plines (psychology, anthropology, computer science, and education) embarking on research with a purpose of changing teaching and learning processes and approaches is supported by [38]. [39] recommend CoP sighting examples like addressing faculty challenges and concerns related to academic writing. The writing communities were created acrossdisciplines holding dialogues for the process of academic writing departments, then facilitating conversation and collaborative activities connected to the process of academic writing. Therefore, in a joint venture activity, there is mutual engagement and mutual collection of ideas towards achieving the institutional goals.

#### **6. Why focus on communities of practice**

According to [3], five key function are offered in CoP. These are:


There are a number of characteristics which promote and drive the CoP for teams. These characteristics create opportunities for team members to develop. **Figure 1** below by [5] demonstrates how CoP contribute to individual members as well as for the organisations for both long term and short term.


**Figure 1.**

*Why focus on communities of practice for members and organisations. Adapted from [5].*

CoP offer support for team members and builds confidence. Individual member gains more information about their practice and they are able to put it into action as they know that they have a reference point, they have cheerleaders and they have literature that supports their properties in the workplace. When an individual is confident about their work from the support that they get from teammates, they constantly feel motivated to do their work effectively. The members know they are not doing work as a duty anymore but they feel in whatever they do they have the support of the teammates or of the organisation and they have some backing from the people who share with them the same beliefs, passions and goals.

The nature of CoP creates opportunities for learning and development. Team members learn from each other as shown by Bandura's social learning theory [31]. Feedback from others is essential as it helps you to develop further as you take time to reflect on your work, improve on areas that are highlighted, and come back to practice with better or improved strategies. Feedback allows one to carry out an action research on what they are doing within the workplace. CoP enables knowledge sharing and reduces duplication. An opportunity for co-contribution to knowledge is created.

Sharing of information allows for more learning and you remember more than having idle information at the back of your mind. When you teach others, you also learn. Sharing of ideas helps an organisation when it comes to empowering employees within the organisation it reduces challenges when an individual who never shared the information that they had about their practice leaves their job without proper training to those remaining behind. When an individual leaves a job, they leave with their expertise and if not careful, you are stuck as an organisation resulting in daunting hand over take over processes. This results in the new incumbent taking longer to perform their duties effectively thereby delaying in yielding results. The community of practice adopts a common approach, which allows scaling [26]. People own the practice, decentralise things, and create consistencies. Community members can act as enablers of change. It is easier for a group to have a voice in an organisation than it is for an individual to try and convince the organisation for change [26].

A community of practice allows for collaboration on common issues and challenges to create better practices. As a team or as an organisation when you are collaborating it allows you to see the challenges together, brainstorm the challenges, come up with ideas on dealing with the challenges and improve based on what findings and the recommendations on what to change and how to change. This result in

a continuous developmental process. According to [40], 'human communities can develop a sort of collective intelligence that is greater than the individual members. Different experiences and sharing allows us to build on each other's experience and improve our practices. CoP therefore are worthy focusing on as they have benefits to the individual and organisations, academic institution included.

## **7. Relevance of communities of practice to professional development**

The relevance of CoP to professional development cannot be overemphasised, it is very important that in CoP, the relationships, interactions and collaborations among group members must not be taken for granted. Such relationships, interactions and collaborations have ways of moulding group members towards their professional development. For instance, academics in their various universities must value their engagements with the members of their CoP. Many achievements towards professional development could be made through CoP, thus, this must be valued and appreciated.

The relevance of CoP to professional development according to [41] are;


*Building Effective Working Relationships among Academics through Participation… DOI: http://dx.doi.org/10.5772/intechopen.95449*

#### **8. Conclusion**

This chapter has pointed out the relevance, importance, and significance of CoPs for the professional development of academics as university teachers. In particular, the enablement, enhancement and support if proffers towards the realisation of a sense of community among academics as teaching and learning practitioners. How academics in their roles as teachers can improve, change, and/ or further develop their teaching practices through engagement, sharing, recognition, and validation of each other's' work are discussed in details. The forming and norming of CoP practices, the different forms that they take, and the various educational functions that they serve are elaborated on. How a CoP comes to have a common understanding of issues that beset them, form a common agenda around the issues, operationalise and develop strategies for dealing with their substantive issues of their practice are highlighted in the chapter. More importantly, this chapter provided details of how effective working relations are developed and nurtured in a CoP.

#### **Acknowledgements**

The authors are grateful to University of Fort Hare, South Africa for funding this research work.

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Author details**

Adeola Folasade Akinyemi\*, Vuyisile Nkonki, Lulekwa Sweet-Lily Baleni and Florence Rutendo Mudehwe-Gonhovi Teaching and Learning Centre, University of Fort Hare, Alice, South Africa

\*Address all correspondence to: aakinyemi@ufh.ac.za

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Katz, S., & Earl, L. (2010). Learning about networked learning communities. Schl Effts &Imprvt, 2010; 21(1): 27-51. https://doi. org/10.1080/09243450903569718

[2] Lave, J., & Wenger, E. Situated learning: Legitimate Peripheral Participation*.* Cambridge, UK: Cambridge University Press; 1991

[3] Wenger, E. Introduction: A social theory of learning. Communities of Practice: Learning, Meaning, and Identity. New York: Cambridge University Press. 1998. p. 3-11. https:// doi.org/10.1017/CBO9780511803932.002

[4] Akinyemi AF, Rembe S, Shumba J, Adewumi TM. Collaboration and mutual support as processes established by communities of practice to improve continuing professional teachers' development in high schools. Co Edu. 2019; 6:1685446. https://doi. org/10.1080/2331186X.2019

[5] Wenger, E., McDermott, R. A., & Snyder, W. Cultivating communities of practice: A guide to managing knowledge. Harvard Business Press. 2002.

[6] Wenger, E., & Wenger, B. (2015). Communities of Practice: A Brief Introduction [Internet]. 2015. Available from: http://wenger-trayner.com/ wp-content/uploads/2015/04/07- Brief-introduction-tocommunities-ofpractice.pdf [Accessed: 2020-11-15]

[7] Chappuis, S., Chappius, J., & Stiggins, R. Supporting Teacher Learning Teams. Ass for Superv & Curr Dev. 2009; 66(5): 56-60.

[8] Jita, L. C., & Ndlalane, T. C. Teacher clusters in South Africa: Opportunities and constraints for teacher development and change. Persp in Edu. 2009; 27(1): 58-68.

[9] Lassonde, C., & Israel, S. Teacher collaboration for professional learning facilitating study, research and inquiry communities. San Francisco, CA: Wiley & Son Inc. 2010

[10] McDermott, R. Knowing in Community: 10 Critical Success Factors in Building Communities of Practice [Internet]. 2000. Available from: http:// www.co-i-l.com/coil/knowledgegarden/cop/knowing.shtm [Accessed: 2020-11-14]

[11] Wenger, E. C., & Snyder, W. M. Communities of practice: The organizational frontier. Harvard Bus Rev. 2000; 78(1): 139-146.

[12] Dalkir K. Knowledge Management in Theory and Practice. Oxford: Elsevier-Butterworth Heinemann:2005.552p.

[13] Lima, J., Carvalho, C., & Laboissiere, A. P. Knowledge Management in Virtual Communities of Practice. In Pasi Virtanen and Nina Helander (Eds.) [Internet]. 2010. Available on: http://www. intechopen.com/books/knowledgemanagement/knowledge-managementinvirtualcommunities-of-practice [Accessed 2020-11-16]

[14] Wilding, C., Curtin, C., & Whiteford, G. Enhancing Occupational Therapists' Confidence and Professional Development through a Community of Practice Scholars. Aust Occup Ther J. 2012; 59: 312-318. https:// doi:10.1111/j.1440-1630.2012.01031.x

[15] Daniel BK, Sarkar A, O'Brien D. A Participatory Design Approach for a Distributed Community of Practice in Governance and International Development. Paper Presented at the World Conference on Educational Multimedia, Hypermedia and

*Building Effective Working Relationships among Academics through Participation… DOI: http://dx.doi.org/10.5772/intechopen.95449*

Telecommunications. Lugano: Switzerland; 2004, p. 4606-4613.

[16] Friberger MG, Falkman G. Collaboration Processes, Outcomes, Challenges and Enablers of Distributed Clinical Communities of Practice. Behv & InfoTech. 2013; 32(6):519- 531. https://doi.org/10.1080/01449 29X.2011.602426

[17] Akinyemi AF, Rembe S, Nkonki V. Trust and Positive Working Relationships among Teachers in Communities of Practice as an Avenue for Professional Development. Educ. Sci. 2020;10(5):136. https://doi. org/10.3390/educsci10050136

[18] Dubé L, Bourhis A, Jacob R. Towards a Typology of Virtual Communities of Practice. Int J Infor Know and Mgt. 2006; 1:069-093. https://doi.org/10.28945/115

[19] Agrifoglio, R. (2015). Knowledge Preservation through Community of Practice. Cham: Springer Nature; 2015. https://doi. org/10.1007/978-3-319-22234-9

[20] Mudehwe-Gonhovi, F. R., Galloway, G., & Moyo, G. Dialogic pedagogical innovation: Creating liberating learning practices for first year university students. South African J of H Edu. 2018; 32(5): 140-157.

[21] Quennerstedt, M., & Maivorsdotter, N. The role of learning theory in learning to teach. Routledge Handbook of Physical Education Pedagogies. New York: Routledge; 2016. p. 417-427. http:// urn.kb.se/resolve?urn=urn:nbn:se:oru:d iva-53836

[22] Patton, K.; Parker, M. Teacher education communities of practice: More than a culture of collaboration. Teach.Teach. Educ. 2017; 67: 351- 360. https://doi.org/10.1016/j. tate.2017.06.013

[23] Poultney, V. Professional Learning Communities and Teacher Enquiry. St. Albans, UK: Critical Publishing; 2020. 160p

[24] Iverson, J. O., & McPhee, R. D. Knowledge management in communities of practice: Being true to the communicative character of knowledge. Mgt Comm Quart. 2002: 16(2): 259-266. https://doi. org/10.1177/089331802237239

[25] West-Burnham, J.; Otero, G. Educational Leadership and Social Capital. Natl Coll for Schl Leadp. 2004; 29:1-2.

[26] Webber, E. Building Successful Communities of Practice: Discover How Learning Together Makes Better Organisations. London: Drew Limited; 2016. 64p.

[27] Reed, M. S., Evely, A. C., Cundill, G., Fazey, I., Glass, J., Laing, A. & Stringer, L. C. What is social learning? Eco & Soc. 2010; 15(4). DOI: 10.5751/ ES-03564-1504r01

[28] Couros, A. Communities of practice: A literature review [Internet]. 2003. Available on: https://pdfs. semanticscholar.org/ab72/67efe8965 d0957f324f87c186c7d8d973842.pdf?\_ ga=2.81645911.1536362757.1606290123- 612571883.1605773803 [Accessed 2020-11-25]

[29] Wenger, E. Communities of practice in and across 21st century organizations [Internet]. 2006. Available from: http:// sitios.itesm.mx/va/dide2/enc\_innov/ doctos/Article21\_century\_organizations. pdf [Accessed: 2020-11-25]

[30] Wenger, E. A social theory of learning. Contemporary theories of learning. In: Knud Illeris (editor). Contemporary Theories of Learning: Learning Theorists – In Their Own Words. London: Routledge. 2009. 256p. https://doi.org/10.4324/9780203870426

[31] Farnsworth V, Kleanthous I, Wenger-Trayner E. Communities of practice as a social theory of learning: A conversation with Etienne Wenger. Brit J Edu Stud. 2016; 64(2): 139-160. https:// doi.org/10.1080/00071005.2015.1133799

[32] Wenger, E., Trayner, B., & De Laat, M. (2011). Promoting and assessing value creation in communities and networks: A conceptual framework. The Netherlands: Ruud de Moor Centrum. 2011; 60p.

[33] Heath, M., & Leiman, T. Choosing Change: Using a Community of Practice Model to Support Curriculum Reform and Improve Teaching Quality in the First Year. Imp. CoP in H.Edu. 2017; 183-204. https://doi. org/10.1007/978-981-10-2866-3\_9

[34] Brouwer P, Brekelmans M, Nieuwenhuis L, Simons RJ. Communities of practice in the school workplace. J Ed Admin. 2012; 50 (3): 346-364. https:// doi.org/10.1108/09578231211223347

[35] Madeleine Schultz, M, & O'Brien, G. The Australian Chemistry Discipline Network: A Supportive Community of Practice in a Hard Science. In McDonald, J., & Cater-Steel, A, Implementing communities of practice in higher education. Berlin, Germany: Dreamers and schemers, Springer; 2016. p. 501-530

[36] Smith, T. (2006). Becoming a teacher of mathematics: Wenger's social theory of learning perspective. Ident, Culr & Lear Spa. 2006: 619-622.

[37] Bray, M. Community Partnerships in Education: Dimensions, Variations and Implications: Thematic Studies. World Education Forum: Education for All. Paris: UNESCO; 2000.

[38] Stein, M. K., Silver, E. A., & Smith, M. S. (2013). Mathematics reform and teacher development: A community of practice perspective. In: James G.

Greeno, Shelley V. Goldman, editors. Thinking practices in mathematics and science learning. 2013. p. 1-39. https:// doi.org/10.4324/9780203053119

[39] Voegele, J. D. C., & Stevens, D. D. Communities of practice in higher education: Transformative dialogues toward a productive academic writing practice. Curri & Instru Fac Publ & Prest. 2017; 45. https://pdxscholar. library.pdx.edu/ci\_fac/45

[40] Pentland, BT. (1992). Organizing moves in software support hot lines. Admin Sci Quart. 1992; 37(4): 527-548. https://psycnet.apa.org/ doi/10.2307/2393471

[41] Cambridge D, Kaplan S, Suter V. Community of practice design guide. Louisville: Educause; 2005.

#### **Chapter 12**

## Challenges of Inter-Professional Teamwork in Nigerian Healthcare

*Obeta M. Uchejeso, Nkereuwem S. Etukudoh, Mantu E. Chongs and Dan M. Ime*

#### **Abstract**

Inter-professional teamwork in government owned hospitals and various healthcare institutions involving various Professionals such as Doctors, Pharmacists, Medical Laboratory Scientists, Medical Laboratory Technicians, Medical Laboratory Assistants, Nurses, Physiotherapists, Radiographers, Health Information Officers, Human Resources Managers, etc. is becoming a challenge leading to various strikes and labour protests in Nigeria. The patients and family relatives and host communities of such health institutions are becoming uncomfortable with quality of care due to inter-professional discord. This needs a critical discussion towards solving/looking into the challenges such as Personality differences, Health Leadership and Hierarchy, Disruptive behaviors, Culture and ethnicity, Generational differences, Gender, Historical inter-professional and intraprofessional education, Fears of diluted professional identification, Differences in accountability, payment and rewards, Concerns regarding clinical roles and responsibilities, Complexity of care, Emphasis of rapid decision making, Service timing, with Associations and Unions. The exploration would provide solutions for better teamwork practice and improved patients care.

**Keywords:** hindrances, challenges, inter-professional, teamwork, healthcare, Nigeria

#### **1. Introduction**

Inter-professional teamwork is where various professionals such as doctors, pharmacists, medical laboratory scientists, medical laboratory technicians, medical laboratory assistants, nurses, physiotherapists, radiographers, health information officers, human resources managers and others who work in the healthcare institutions, work together with patients, care givers, families and communities to deliver the highest quality of care [1].

The World Health Organization (WHO) [2] defined inter professional teamwork or collaboration as a situation where multiple healthcare workers from different professional background work together with patients, care givers, families and host communities to deliver the highest quality of care. This is essential in a situation where health care professionals assume complementary roles and cooperatively work together, sharing responsibilities for a problem solving, and decision to formulate and carryout plans for adequate patient's care.

Available evidence however suggest that unlike in the developed world, health care professionals do not collaborate well in Nigeria because of the claim of

#### *Interpersonal Relationships*

superiority of a particular health professional like physicians who always claim healthcare leadership and owners of patients which creates more conflict among other healthcare professions that is threatening to tear the health care sector apart, to the detriment of the patients [3].

Most of the challenges faced in the health care sector are due to; several month salaries owed, poor welfare, lack of appropriate healthcare facilities and other emerging factors among health workers.

Researchers have found out that working together reduces the number of medical errors and increases patient's safety [4]. Teamwork also reduces issues that lead to burnout, no longer is one person responsible for the patient health. Today, an entire team of health workers come together to coordinate patients' well-being and it reduces both surgical and diagnostic errors [5].

Teamwork is based on solid communication among healthcare workers with the patients and their families sometimes to feel more at ease. They accept treatments and feel more satisfied with the health care [6] when there is good communication backed up by team spirit.

The teamwork significantly reduces workloads, increases job satisfaction and retention, improves patients' satisfaction and reduces morbidity [7].

This chapter shall examine the Nigerian situation on teamwork and the challenges/hindrances which affect the positive outcomes of quality health delivery. Notably, Nigerian Health workers are knowledgeable on the teamwork and the possible positive outcomes [8–10], but the challenging factors have contributed to the less concerns on the teamwork practice and if well addressed, Nigeria shall improve on the next level of positive outcome of healthcare laced with teamwork.

#### **2. Hindrances of teamwork in healthcare sector in Nigeria**

Teamwork has been advocated across the globe. The Nigerian healthcare shows interest in teamwork across healthcare institutions, however some mitigating factors hinder the teamwork spirit and the expected positive outcomes.

#### **2.1 Personal values and expectations**

Knowing that teamwork requires collaboration and understanding within the health care sector, personal values and expectations of team members counts. Personal values have to be well maintained in other to understand each other. Guiding principles and understanding the core mission of work without letting in expectations and one's personal interest to outweigh the team interest is essential.

In Nigeria, personal values and interest, depending on the exposure and family financial base challenges professionals on how well to work as a good team member or not. Poverty and stress attached to financial crisis may limit expected outcome of services or team outcome.

#### **2.2 Professional distribution**

Distribution of health workforce has been another serious challenge due to inadequacy in the recruitment and number of personnel in various health facilities. Abimbola [11] did not mince words when he puts it that the low and inequitable distributions of healthcare workers remain an elephant challenge in the Nigerian healthcare sector. Bangdiwala and colleagues [12] opined that there is a global crisis in health workforce as a system by acute shortage and uneven distribution of health workers in several settings. In Nigeria, expert have reported that historically, "brain

#### *Challenges of Inter-Professional Teamwork in Nigerian Healthcare DOI: http://dx.doi.org/10.5772/intechopen.95414*

drain in the form of migration of health workers to high income settings as a major setback in the country" [13]. Current statistics show that one in four doctors and one in twenty nurses trained in Africa are currently working in developed countries, with this contributing to the short fall of over 1.5 million healthcare workers in the African region [14]. Healthcare workforce density in Nigeria, is estimated at 1.95 per 1000 population [15]. These figures reveals disparity and shortage of health professional man-power and may contributes to less attention to team work. In order to handle the huge workload, there should be due consideration to team work and collaboration which makes workload better handled with ease.

In the midst of unequal distribution of healthcare staff, there is embargo on employment of medical laboratory scientists in many healthcare institutions as compared with Doctors and Nurses. This situation leads to lopsided approach and heavy workload on a particular profession thereby stampeding teamwork especially in patients care management.

#### **2.3 Personality and professional differences**

Personality traits exist in addition to professional differences depending on the different roles as legalized in various countries of practice, an instance of Nigeria.

While some see the practice of medicine as an autonomous one-on-one relationship between the clinician and the patient, others see it as a team work towards a better patient outcome. The challenge emerges when a particular profession in a healthcare setting takes ownership of patient and assumes that other healthcare professionals that come in contact with the patients are not important. This relationship remains a core value in Medicine but it is challenged by many concepts of teamwork and shared care thereby, hindering the sharing of information of their patients through medico-legal implications of team-based care.

Many healthcare workers have shown different views and ways of doing certain thinking in this regards. This serves as a barrier to inter professional teamwork where one behavior or attitude differs from the other and sometimes, the attitudes can be traced to professional differences.

#### **2.4 Hierarchy and health leadership**

Hierarchy among medical professionals in Nigeria is a serious challenge in teamwork practice in Nigeria. Before 1985, the headship of healthcare institutions was not specific but based on the most qualified professional to hold such office. Not until 1985 when Decree 10 was promulgated for the Teaching Hospitals to be headed by Chief Medical Director (CMD) who must be a Physician (Medical Doctor), registered and licensed. This Decree has been replicated in all health institutions without adequate legal backing. This removed the competency in administration and management in Nigerian healthcare to the hands of Doctors who may or may not have the adequate knowledge in practice of administration and management.

Currently, it is difficult to have a health team where the teams' decision would be accepted if the team leader is not a medical doctor. Strong hierarchical nature of medicine graduates rating as number one in Nigerian healthcare sector pushes for only the doctors to be both Ministers as appointed in the Federal Ministry of Health, Health Agencies, State Ministries of Health and all Hospitals. In a typical Nigerian healthcare, most decisions by a team is not accepted if not headed by a Doctor and this has really posed as a challenge to other professions within the sector.

Supremacy/Headship challenge especially in the health institutions leadership has developed an ugly trend of which team works stands better chance to handle. It was Alubo [16] that opined that the health workforce crisis in the country have

taken unique and worrying dimension. In reality, other healthcare workers have alleged that the Nigeria health system is designed to favor doctors mainly, especially in management of health sector not minding if there is certificate or experience in management or not. The alleged dominance of doctors over the years have encouraged other health sector unions (JOHESU) to put up resistance.

In the health care system, different positions and categories are allocated to the health care professionals on the basis of levels. The upper echelons of the hierarchy are superior to the ones occupying the lower level, and thus the communication and collaboration might be formed and therefore serve as a hindrance to interprofessional treatment.

Rosanne [17] posits that difference in attitudes in inter-professional healthcare about who is ultimately in charge could be an "Achilles' heel" across the globe. In Nigeria, the Doctors are fully in charge in all medical interdisciplinary teamwork. There is need to give further attention, because agreement with the concept of shared team decision-making is fundamental to effective interdisciplinary work of any kind. The question of who is in charge is a complex issue with complicated legal, ethical, and professional ramifications.

#### **2.5 Disruptive behavior**

Most health workers want to be given full attention alone. When this occurs, teamwork cannot be enjoyed; because others might feel less valued and would not be listened to. This serves as a barrier in inter-professional team work.

The situation where every health professional in Nigeria threatens for work to rule, strike and industrial actions based on one issue or the other with other disruptive behaviors makes it very impossible to continue team spirit in healthcare in Nigeria.

#### **2.6 Culture and ethnicity**

While there has been a growing acknowledgement that teamwork is important in health care, this has not necessarily been translated into changed practices, especially in emerging and developing nations like Nigeria where cultural norms of communication may mitigate against teamwork. Communication gap is huge because of Federal Character and Catchment area policies of government.

In the healthcare sector in Nigeria; culture and ethnicity serves as a gap in team work. When a client and a health professional are from different background; the difficulty in language, communication and understanding occurs. It might be hard to get a translator and this therefore, ends the means of achieving a goal. Different clients come from different background; therefore the means of understanding within the healthcare system is limited.

Some culture or practices maybe due to religion. This may pose a challenge especially where women abhor medical attention from men or vice versa.

#### **2.7 Generational differences**

Having a varied generation representing a team will create a barrier in interprofessional teamwork, some health workers have a particular age range; and might have some ideas, attitude or values. When these cannot be maintained, it creates so many differences. The generation gaps puts the just graduated health professional who may be probably doing Internship and full of information communication technology (ICT), savvy to have different approaches to case managements as team members with others who have grown from the ranks while working as a team. The

ethical issues serves as a bridge but in some cases, the idea of a junior colleague or team member may be logical but not tolerated in terms of respect and ethics from the senior ones and creates some differences as a team.

#### **2.8 Gender**

Following the medical practice history, women were nurses and men were physicians; but recently, men are becoming nurses and more women are becoming physicians, although men represents only 7% of the nursing population, and medicine is almost equally represented by both men and women. A study by Wear & Keck-McNulty [18] and Lotan [19] supports the concept that female nurses are more collaborative with female physicians, the result from the qualitative survey shows that female nurses reported higher level of collaboration with female physicians than male physicians. Gender has always been a barrier to collaborative healthcare achievements due to issues concerning on whom to be given several position between a man and a woman [20]. Gender equity in any health team is very important [21].

Gender sensitivity is very import in formation of good teams. In cases were professional members are dominated by men or women, such gender differences poses some challenges in the team performance.

In Nigeria, the women are more among the nurses and men are more among other professionals though there is serious improvement towards mixing the gender unconsciously. In some critical cases, women are required especially to attend to women concern on special or personal preference within the team, but where they are lacking it poses more challenge to the teamwork.

#### **2.9 Historical inter-professional and intra-professional education**

Various healthcare professionals have different educational backgrounds especially in Nigeria where all professions – Physicians, Pharmacists, Medical laboratory scientists, Nurses etc. have their root traced to other countries of the world. In Nigeria, most of the professions started as Certificates, Diploma, and Degrees.

Take for instance, the training of Medical laboratory scientists originated from London [22]. The first categories of the professionals went to London to train as medical laboratory assistants, technicians and technologist. But currently, it is in country training as medical laboratory scientist of which their background of training or professional status should not be a barrier to teamwork with other healthcare professionals. When various professionals look at historical evolution and education rather than harnessing capacities to improve teamwork, it poses a challenge.

#### **2.10 Fears of diluted professional identification**

There exists fear of one profession thinking that another profession would learn the job and practice the profession without licensure and adequate certification because of collaborative work as noted in teamwork.

While teamwork enthrones collaboration and sharing of ideas based on professional skills and knowledge, the authors believe that it does not take ones professional status away or dilutes professional identification. However, this fear dominates Nigerian healthcare team practice.

#### **2.11 Differences in accountability, payment and rewards**

Dispute over accountability, salaries, rewards and allowances in the Nigerian healthcare sector have continued to emerge day in day out among other factors.

#### *Interpersonal Relationships*

Poor remuneration and welfare has also been identified with cases of partiality depending on the professionals involved. The increasing cost of goods and services in Nigeria with increased inflation rates has made it possible that no amount paid to health workers will be enough to satisfy them. Oleribe [23], reported that poor remuneration and wages, poor welfare of the healthcare workforce have led health workers to embark in numerous industrial action due to several month salaries owed and poor working conditions. This strikes and threats of strike continues unabated even at the time of writing this chapter.

In a recent survey of senior management staff of health institution in Nigeria, massive discrepancies in remuneration of health workers in the same grade level across federal, state and local government were observed [24].

Payment and reward are determined based on the position and levels of the professional and this therefore can be mistaken and seen as a means of underrating a particular worker.

In Nigeria, various payment and salary structures exist. We have Consolidated Medical Salary Structure (CONMESS), salary scale for medical doctors and Consolidated Health Salary Structure (CONHESS) for other healthcare professionals. The challenge is that CONMESS puts medical doctors more important in healthcare as other professionals lament frequent review of CONMESS and not same for CONHESS. The argument is that the Chief Executives who are all medical doctors prefer to favor their colleagues to the detriment of other professionals.

This is a major factor affecting the team spirit as it is evident that a team comprising of Doctor, Pharmacist, Medical laboratory scientist, Nurse, Radiographer, and Physiotherapist who are in the same grade level shall definitely go home with different amount as wages and emolument even though they are in the same team.

#### **2.12 Concerns regarding clinical roles and responsibilities**

Currently in Nigeria, there exists considerable changes and overlapping in the professional roles played by different health professionals. Ordinarily, from the training levels, there are basic inter-professional expositions of what the health professionals do up to practical terms for knowledge sake but all professionals are licensed to practice their profession [20]. For instance, radiographers can read plain film X-rays, Clinicians, Nurses, Pharmacists can perform some simple medical laboratory tests and their various professional license of practice may not cover such areas as prescribed by law regulating their various practices. These changing roles and task shifting leads to some team challenges in terms of role allocation and acknowledgement.

#### **2.13 Complexity of care**

Complexity of care may involve changing settings based on the fact that "nature of health care is changing including, increased delivery of care for chronic conditions into community care and many surgical procedures to day-care centres. These changes require the development of new teams and the modification of existing teams" [20] thereby causing instability of teams.

Health-care teams can be transitory in nature, as it is when coming together for a specific task or event (such as cardiac arrest teams or molecular testing teams). The transitory nature of these teams places great emphasis on the quality of training for team members. This raises challenges in medical care where education and training is often relegated at the expense of service delivery [25]. This is because, most healthcare managers in Nigeria lay emphasis on doing the job than more training for the healthcare professionals who do the job.

The complexity of care is found in intensive care nursing, surgical cases, molecular and advanced techniques in medical practice associated with the severity of illness and the caring intensity which poses threat to teamwork.

#### **2.14 Emphasis of rapid decision making**

Decision making with regards to teamwork helps the health workers to be open in discussions. When the decisions are made from certain workers without others involved in such discussion, it creates a teamwork challenge and thus can lead to misunderstanding among the healthcare professionals. This could be due to differences in status among the health workers. And others might feel that their ideas are not welcome, and therefore reduces their efforts. This has been the case where decisions are taken for medical laboratory services in Nigeria in absence of medical laboratory scientist in most management decision-makings in various Nigerian hospitals. Such decisions could be challenged or some approvals returned unattended to due to the lacuna or professional errors. The team spirit diminishes leading to job dissatisfaction [26] in cases where some medical laboratory reagents and consumables are approved or even purchased without adequate input by medical laboratory scientist on the validity and certification of such products towards quality outcome.

#### **2.15 Time**

Lack of time is a barrier to collaboration and achievement of goals. Time must be given to all team members to collaborate including the clients. Due to the shortage in nursing profession; nurses today have larger patients' number to attend to providing for a limited amount of time to spend with each patient. Combined parttime work with increase patient loads and there is a little for health care providers to interact with each other and their patients. Collaboration requires trust and to build trust; people need time for interaction [20]. Due to shortage of health professionals in Nigeria most especially medical laboratory scientists in various hospitals possibly because of increased unemployment created by healthcare managers and Chief Executives who are Physicians, the robust interaction time in teamwork practice is affected because of the crowded patients in need of attention and numerous samples for analysis with reference to the medical laboratories.

#### **2.16 Associations and unions**

In Nigeria, associations and unions are very strong forces that affect team work in Nigerian healthcare. There are numerous associations as each professional body has their association and related ones went ahead to form unions and recently, some unions joined to form common front for strong bargaining power with the government and that lead to formation of the Joint Health Sector Union (JOHESU). JOHESU consist of five registered health professional unions; Medical And Health Workers Union Of Nigeria (MHWUN), National Association Of Nigerian Nurses And Midwives (NANNM), Senior Staff Association Of Universities Teaching Hospitals, Research Institutions and Associated Institutions (SSAUTHRIAI), Nigerian Union Of Allied Health Professional (NUAHP), and Non Academic Staff Union Of Educational And Associated Institutions (NASU).

On the other hand, the Nigeria Medical Association (NMA) is umbrella association of all Medical Doctors/Physicians in Nigeria. There are other sub group associations of NMA depending on their area of specialization or the level of practice.

The team work becomes a hard nut to crack in Nigerian healthcare sector for the fact that NMA do not believe that anything good can come out of JOHESU and vice versa. Such has grown to its obnoxious apogee to the extent that what government approves for JOHESU professional members are being opposed by NMA not minding how good the package may add to healthcare practice or to the motivation and job satisfaction of the beneficent. In the course of writing this chapter, the authors observed that an approval by government to Pharmacists (**Figure 1**) was challenged by NMA on the 16th September, 2020 when their National publicity secretary, Dr. Aniekeme Uwa posited that NMA "will find a permanent solution to the unwarranted assault on the integrity of the noble profession" followed by the JOHESU members and leadership while commending the federal government of Nigeria on behalf of Pharmacists the Secretariat released a statement of the 18th September, 2020 and "wonders how the approval of a consultant cadre in Pharmacy practice would amount to an assault on the integrity of medical practice". JOHESU expects the government to extend the Consultant status to other healthcare professionals as the consultant cadre in health systems is not a sole attainment of a particular profession.

NMA 24 Point agenda and JOHESU 15 Point demands has been two major causes of strike and industrial actions in Nigerian Health industry. Most of the time, the need of one is in direct opposition to the other and makes the dispute resolution not in any way near in Nigeria.

JOHESU demands and counter demands by NMA and vice versa has reached its obnoxious apogee that disbanding the Associations and unions may not really be the solution. For example, the NMA and JOHESU strike in 2014 were based on doctors/nurses, doctors/pharmacists, doctors/medical laboratory scientists, doctors/allied health professionals protracted supremacy challenge.

**Figure 1.**

*Approval of consultant cadre for Nigerian pharmacists.*

*Challenges of Inter-Professional Teamwork in Nigerian Healthcare DOI: http://dx.doi.org/10.5772/intechopen.95414*

In the last 10 years, there have been calls to address those prevailing issues especially on the provision of better facilities for disease diagnosis and treatment, improved health workforce and remuneration and a health care scheme. On notable response in the National Health Act, which was signed into law by the former president Goodluck Jonathan on October 31, 2014, Albeit generated diverse disagreement and interest among various health professionals and stakeholders in the preceding 5 years [27].

The goal of the health sector is to ensure delivery to affordable, accessible, equitable and safe health services to the population and in achieving this, every health workforce has an important role to play. However, the challenge posed by associations and unions in Nigerian healthcare is a major hindrance to teamwork.

#### **3. Approaches to good teamwork in healthcare sector in Nigeria**

For a healthcare sector to attain a good team work; health professionals must know how to practice collaboration with improved communication and partnership among all health providers and patients; Clarity on the role of all healthcare providers working within team environment; Better response processes in addressing issues related to healthcare; Effective utilization of health care resources. This leads to team's provision of healthcare services and high level of satisfaction on delivery of services among team members [28–30].

All effort should be in place in Nigerian healthcare institutions so as to mind every one's values and assumptions that affect interactions with team members who are definitely other professionals. No matter the strengths and weaknesses of different team members, good teamwork helps to deliver quality and safe care [31–33].

Psychosocial factors of team members should not be allowed to affect team interactions. However, the impact of change on team members should be recognized. There is a need for the healthcare leadership to organize workshops and training [34] on teamwork and conflict management with the aid of role plays with small groups and ability of healthcare managers to understand the characters of stress and conflict within the system. Such programmes improves knowledge [35]. Professionals' development among healthcare teams cannot be ignored while encouraging all professionals to show respect for each other [36, 37].

Training and practice of emotional intelligence (EI) helps the care givers and healthcare managers in resolving conflicts. It is also imperative to use personality traits and characteristics instrument like crew resources management (CRM) or core self-evaluation (CSE) on conflicts to assess team members who have conflict or less conflict traits.

Also, break the barriers of team communication gaps in healthcare through teaching effective communication strategies, training team members together within undergraduate and postgraduate levels and during team formation stages, stimulate team members together during training or work, redefine healthcare team members to include all healthcare professionals, and make teams democratic in nature in all strata of communication. The healthcare teams should be supported with protocols and procedures such as check lists, IT solutions and briefings and adequate development of organizational culture that support healthcare teams [38].

Patients are the center of every medical team and there is a need to include them as team member in any team function.

The hierarchy of professionals over others should be well considered so that no one profession is exalted over other in healthcare team considering that everyone is very important. It should be however put that the heads of any team should be the most qualified and experienced based on years of service and certifications in management and administration, no matter the professional affiliation. It will not be a bad idea if postgraduate certificate in management and administration is requested from prospective Ministers of Health, Chief Executive Officers of Hospitals and healthcare institutions, no matter the profession towards health leadership in Nigeria. The authors recommend such postgraduate certificates that are not less than Master of Science (MSc) in management or administration, Master of Public Administration (MPA), Master of Business Administration (MBA), Master of Health Administration (MHA), Master of Health Management (MHM), and Master of Human Resource Management (MHRM).

Mutual support techniques should be employed in resolving conflicts, using communication techniques [28] while changing and observing behaviors of medical teams. Such support is expected of NMA and JOHESU to each other where the success of one is success of all in the healthcare industry. The NMA is not the government and neither is JOHESU and both should partner in requesting from the government for better healthcare in Nigeria rather than sabotaging each other before the government especially in the aspect of remuneration, promotion and approval of consultant status for other medical and health professionals in the spirit of teamwork.

There should be a close review and consideration by the Nigerian Federal Ministry of Finance and Budget and Planning Office to reconsider review of Salaries of all Medical and Health practitioners in Nigeria. This shall ensure that a team comprising of Doctor, Pharmacist, Medical laboratory scientist, Nurse, Radiographer, and Physiotherapist who are in the same grade level shall definitely go home with same amount as wages and emolument when they are in the same team and same salary grade level. Having considered the length of training during entry points for all professionals in Nigeria, it is germane to pay equally all team members no matter their profession when they are at the same grade level in a team. For example, if all team members are at Chief Level (Grade Level 14) all of them should be paid the same salary. The authors call the attention of Nigerian government as a measure to deal with incessant strike actions among healthcare workers in Nigeria, to work out a uniform salary structure when all health workers can be paid or revert back to normal salary grade level with adequate allowances for all and not necessarily CONHESS and CONMESS. Though entry points of various professionals may differ, when all those in same level are paid equally, the team spirit shall be encouraged and strengthened.

There is an urgent need in the Nigerian health system to build sustainable leadership, through national health system administration policy that allows alignment consideration and coherence of priorities and partnership in the health workforce and among various stakeholders [39, 40] towards a formidable team work which would provide an improved outcome of patients who are the customers in the healthcare industry [41, 42].

Round table for all health professionals and inter-professional training may help as they may tend to table their challenges, and rub minds on the best approach to teamwork and conflict resolution.

Teamwork involving all professionals is urgently needed as it creates understanding of importance of all professionals involved to operate in harmony [43, 44]. Currently, the teams experiences in Nigeria are of one profession with varying levels but the team spirit should cut across all health professionals.

The mutual distrust tension and supremacy challenge among the health workforce need to stop as a matter of priority. The focus of health service should be on teamwork rather than factional or individual strength [45].

There is need to design a contextually adaptable framework for inter professional education and collaboration practice in the health sector as recommended by WHO, to further facilitate successful cooperative communication and teamwork in health care service delivery and ensure a healthcare needs and delivery [46].

#### **4. Conclusion**

The inter-professional or interdisciplinary healthcare teams face a set of challenges that are not necessarily encountered by other types of team such as uni-disciplinary or non-health care teams. The importance of inter-professional teamwork is increasingly recognized in healthcare administration and management as possible positive outcomes outweigh the disadvantages. There is improved quality of healthcare for patients, community and healthcare professionals.

Teamwork is difficult to tackle, while making the environment become more complex. But if there is focus on the part of the team, the challenges can be overcomed through workshop and training, joint professional training, improved communication strategies, putting aside professional differences, adequate remuneration of the teams based on their levels and allowing all professionals who are qualified to lead a healthcare team to do so without singling out a particular profession as healthcare leaders.

For teamwork to be updated and applied in the Nigerian healthcare, various healthcare professionals such as Doctors, Pharmacists, Medical Laboratory Scientists, Medical Laboratory Technicians, Medical Laboratory Assistants, Nurses, Physiotherapists, Radiographers, Health Information Officers, and Human Resources Managers should put aside personality and professional differences for the team interest; ensure qualified and certified health leadership and hierarchy; stop disruptive behaviors; neutralize culture and ethnicity interferences; blend the generational differences; ensure gender equity and fair play; work with current status and knowledge without historical inter-professional and intra-professional education; remove fears of diluted professional identification; Ensure accountability, payment and rewards to which ever profession as due without discrepancies and antagonism; Respect all professional roles and responsibilities; carry all along in decision making; provide services with a good turnaround time; and show less interest in Associations and Unions when it comes to team work but adequately manage it with government towards successful teamwork and good healthcare practices.

#### **Acknowledgements**

The authors wish to acknowledge all those who are working hard to enthrone teamwork in Nigerian healthcare sector.

#### **Conflict of interest**

The authors declare no competing interests.

## **Notes/thanks/other declarations**

Obeta M. Uchejeso conceptualized the Chapter, Obeta M. Uchejeso, Nkereuwem S Etukudoh, Mantu E. Chongs, and Dan M. Ime wrote the manuscript; Obeta M. Uchejeso, Nkereuwem S Etukudoh, Mantu E. Chongs, and Dan M. Ime edited the chapter and approved the final manuscript for submission.

## **Author details**

Obeta M. Uchejeso1,4\*, Nkereuwem S. Etukudoh2 , Mantu E. Chongs3 and Dan M. Ime1

1 Department of Medical Laboratory Management, Federal School of Medical Laboratory Science, Jos-Nigeria

2 Office of the Provost/CEO, Federal School of Medical Laboratory Science, Jos-Nigeria

3 Department of Special Duties, Federal School of Medical Laboratory Science, Jos-Nigeria

4 Department of Public Administration and Local Government, University of Nigeria, Nsukka-Nigeria

\*Address all correspondence to: uchejesoobeta@gmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Challenges of Inter-Professional Teamwork in Nigerian Healthcare DOI: http://dx.doi.org/10.5772/intechopen.95414*

#### **References**

[1] Obeta MU, Etukudoh NS, Udenze C, Eze ME. (2020). Inter-Professional Teamwork in Public Organizations, A Paradigm Shift to Crisis in Nigerian Hospitals. London Journal of Medical and Health Research; 20(3)1 Pg 31-40

[2] WHO (2016): World Health Care Organization in Nigeria: Global Health Workforce Alliance. Geneva: World health Organization 2016.

[3] Adeloye D, Rotimi AD, Adenike AO, Asa A, Adedape A, Mukhtar G, Jacob KO, Oluwafem O, Alexander l. (2017). Health workforce and governance: The crisis in Nigeria. Human resources for health 15:32.

[4] Bakker, A. B., Demerouti, E., & Schaufeli, W. B. (2005). The crossover of burnout and work engagement among working couples. Human Relations, 58, 661-689

[5] Rosen MA, Granados DD, Dietz AS, Benishek LE, Thompson D, Pronovost PJ, Weaver SJ. (2018). Teamwork in Healthcare: Key Discoveries Enabling Safer, High Quality Care. American Psychology; 73(4): 433- 450. doi:10.1037/amp0000298.

[6] Mickan, S.M. (2005). Evaluating the effectiveness of health care teams. Australian Health Review; 29:211-217

[7] Virani T. (2012). Inter professional Collaboration Teams. Canadian Health Services Research Foundation and Canadian Nurses Association 2012.

[8] Ogbonnaya C. (2019). Exploring possible trade-offs between organizational performance and employee well-being: The role of teamwork practices. Human Resource Management Journal; 1-18. https://doi. org/10.1111/1748-8583.12238

[9] Iyoke CA, Lawani LO, George Ugwu GO, Ajah LO, Ezugwu EC, Onah P, Onwuka CI. (2015). Knowledge and attitude toward interdisciplinary team working among obstetricians and gynecologists in teaching hospitals in South East Nigeria. Journal of Multidisciplinary Healthcare; 8: 237-244

[10] Onyekwere LA. (2013) Inter professional Collaboration and Work Efficiency in Secondary Health Delivery System in Rivers State. International Journal of Scientific Research in Education. 6(1), 9-49.

[11] Abimbola S, Molemodile SK, Okonkwo OA. (2016). 'The government cannot do it all alone': realist analysis of the minutes of community health committee meetings in Nigeria. Health Policy and Planning 31: 332-45.

[12] Bangdiwala SI, Fonn S, Okoye O, Tollman S. (2010). Workforce resources for health in developing countries. Public Health Review; 32(1):296-318. doi: 10.1007/BF03391604.

[13] Ike, S.O. (2007). The Health Workforce Crisis: The Brain Drain Scourge. Nigerian Journal of Medicine; 16:204-11.

[14] World Health Organization, WHO (2014). World Health Statistics 2014. Geneva: World Health Organization; Health systems. 128-140.

[15] WHO. (2016). World Health Reports; working together for health, WHO, Geneva, 2016.

[16] Alubo, S.O. (1985). Underdevelopment and the Health Care Crisis in Nigeria. Medical Anthropology; 9(4):319-335. https://www.ncbi.nlm. nih.gov/pubmed/3870520

[17] Rosanne ML, Kathryn H, Kirsten E, Sylvan W, Maria LV, Susan F, Christine KC, Judith LH. (2002). Attitudes Toward Working on Interdisciplinary Healthcare Teams: A Comparison by Discipline. Journal of American Geriatrics Society 50:1141-1148.

[18] Wear D, & Keck-McNulty C. (2004). Attitudes of female nurses and female residents toward each other: A qualitative study in one US teaching hospital. Academic Medicine, 79(4), 291-301. doi:10.1097/00001888- 200404000-00004

[19] Lotan DW. (2029). Female nurses: Professional identity in question how female nurses perceive their professional identity through their relationships with physicians Cogent Medicine; 6: 1666626. https://doi.org/10.1080/23312 05X.2019.1666626

[20] Lori FT, Barbara VF. (2008). Interdisciplinary Collaboration for Healthcare Professionals. Nursing Administration Quarterly. (32) 1, 40-48.

[21] Mathieu B, Michelle M, Lihui X, Tana W, Khassoum D, Jim C. (2019). Gender equity in the health workforce: Analysis of 104 countries. Health Workforce Working paper 1 for WHO.

[22] Ozuruoke DFN.(2014). History of Medical Laboratory Science: Nigeria in perspective. Lagos: Pundit Publishers

[23] Oleribe OO, Iheaka PE, Olabisi O, Akinola EP, Udofia D, Osita-Oleribe P, Taylor- Robinson SD. (2016). "Industrial Action by Healthcare Workers in Nigeria in 2013-2015: Causes, Consequences and Control: A Cross- sectional Descriptive Study."

[24] Omoluabi E. (2014). Needs assessment of the Nigerian health sector. Abuja: International Organization for Migration.

[25] Cologne M, Zanilli D, Saiani L. (2010). Complexity of Care: Meaning and Interpretation Assistenza Infermieristica ericerca AIR 29(4):184-91, 2010.

[26] Obeta MU, Goyin LP, Udenze C, Ojoh J. (2019). Assessment of Job Satisfaction Indices among Health Professionals in Jos University Teaching Hospital: An Analytical Study. IOSR Journal of Business and Management (IOSR-JBM), 21(2) 38-50 DOI: 10.9790/487X-2102043850 www. iosrjournals.org

[27] Enabuele O, Enabuele J. E, (2016). Nigeria's National Health Act; an assessment of health professionals; knowledge and perception. Nigeria Medical Journal 57(5)260-261.

[28] Nancarrow SA, Booth A, Arias S, Smith T, Enderby P and Roots A. (2003). Ten Principles of good interdisciplinary teamwork. Human resources for Health 2013;11:19. doi: 10.1186/1478-4491-11-19.

[29] Michelle O. D. & Alan A. R. (n.d). Professional communication and Team collaboration. Patient safety and quality. An evidence based Handbook for Nurses. Vol. 2.

[30] Lincoln C, Timothy E, Sudhir A, Jo Ivey B, Hilary B, Mustaqueb C, Marcos C, Lola D, Gilles D, Gibs E, Elizabeth F, Demissie H, Pita H, Marian J, Christopher K, Sarah M, Ariel P, Nelson S, Giorgio S, Barbara S, Alex D, Suwit W. (2004). Human Resources for Health: Overcoming the Crisis, Public Health 364:1984-1990

[31] Katib IK. (2011) Quality management in the Nigerian health system; A case study of Isalu Hospital Limited, Ogba Lagos. International journal of economic development Research and investment, 2(1): 161-169.

[32] Oandasan I, Baker GR, Baker K, Bosco C, D'amour D, Jones L, Kimpton S, Louise LC, Louise N, Leticia SMR, Tepper J, Way D. (2006). Teamwork in healthcare: Promoting Effective Teamwork in Health care

*Challenges of Inter-Professional Teamwork in Nigerian Healthcare DOI: http://dx.doi.org/10.5772/intechopen.95414*

in Canada. Canada Health Services Research Foundation, Ontario.

[33] Bernard O. and Rashidat A. (2014). Organizational Conflicts: Causes, Effects and Remedies. International Journal of Academic Research in Economics and Management Sciences. 3(6).

[34] Weaver SJ, Dy SM, Rosen MA. BMJ Qual Saf 2014;23:359-372. doi:10.1136/ bmjqs-2013-001848

[35] Mikkelsen E.G., Hogh A. & Puggaard L.B. (2011) Prevention of bullying and conflicts at work. International Journal of Workplace Health Management 4(1), 84-100.

[36] Almost J, Wolff AC, Stewart-Pyne A, Mccormick LG, Strachan D, D'Souza C. (2016) Managing and mitigating conflict in healthcare teams: an integrative review. Journal of Advanced Nursing 72(7), 1490-1505. doi: 10.1111/jan.12903

[37] Pavlakis A, Kaitelidou D, Theodorou M, Galanis P, Sourtzi P, Siskou O. (2011) Conflict management in public hospitals: the Cyprus case. International Nursing Review 58(2), 242-24

[38] Weller J, Boyd M, Cumin D. Postgrad Med J 2014;90:149-154. doi:10.1136/ postgradmedj-2012-131168

[39] Disu AS. & Obeta MU. (2018) Strategic Analysis of Job Motivation in Nigeria's Health-Care Sectors. Transafrican Journal of Contemporary Research (TJCR) International Journal of Sustainable Development, vol. 1. No. 2, Pp.152-163; June 2018, Jos, Transafrican Links, www. transafricaonline.com

[40] Senkubuge F, Modisenyane M, Bishaw T. Strengthening health systems by health sector reforms. Glob Health Action. 2014;7:23568. doi: 10.3402/gha. v7.23568.

[41] Baguma JC and Obeta MU. (2020). Managing Quality in Health and Social Care Services; an Exemplary Review of a Center in London. Journal of Quality in Health care & Economics. https://doi. org/10.23880/jqhe-16000157

[42] Obeta MU, Maduka MK, Ofor IB, Ofojekwu NM. (2019). Improving Quality and Cost Diminution in Modern Healthcare Delivery: The Role of the Medical Laboratory Scientists in Nigeria. International Journal of Business and Management Invention (IJBMI), 08(03) 08-19. www.ijbmi.org

[43] Erhabor O, and Adias TC. (2014): Harmony in Health Sector: A requirement for Effective Healthcare Delivery in Nigeria. Asian Pacific Journal Of Tropical Biomedicine August 2014,4(12): 925-929.

[44] Erhabor O, Okara GC, Adias TC, Erhabor T, Erhabor U. (2020). Professional Autonomy in the Running of Medical Diagnostic Laboratories in Nigeria. Journal of Medical Laboratory Science, 2020; 30 (3): 107-135. http:// doi.org/10.5281/zenodo.4048920

[45] Akinyemi O, Atilola O. (2013). Nigerian resident doctors on strike: insights from and policy implications of job satisfaction among resident doctors in a Nigerian teaching hospital. The International Journal of Health Planning and Management. 1-16. DOI: 10.1002/ hpm.2141

[46] WHO. (2010) World Health Organization. Framework for action on inter professional education and collaborative practice. Geneva.

#### **Chapter 13**

Perceptive Chapter: "Are We Listening?" - Improving Communication Strategies and Relationships between Physicians and Their Patients

*Martha Peaslee Levine*

## **Abstract**

We talk about the "art" of medicine because medicine is more than science. The science portion drives diagnosis and treatment. However as more tests become available, the art of the relationship and communication with patients is being steadily lost. Physicians often interrupt their patients only seconds into the interview. If we stop their story that quickly, we are not listening to what they have to say. If we do not listen to their story, how can we understand their illnesses and the effects on their lives? This chapter will examine physician-patient relationships by looking at ways to help foster these relationships and what can hinder them. We need to actively listen to our patients, listening for clues about their illness and/or suffering. We need to use observation and our emotions to understand the context of their illness. Examples will be included to help elucidate some of the challenges. Models that can provide a framework for communication will be discussed. Suggestions for ways to help improve communication and interpersonal relationships between physicians and their patients will be offered. This chapter will provide a chance to think about improving communication with our patients to help strengthen our interpersonal relationships.

**Keywords:** communication, physician-patient relationships, active listening, art of medicine

## **1. Introduction**

When physicians practice the "art" of Medicine, the art portion includes well-developed diagnostic skills to sleuth out the cause of a patient's complaint. However one of the most important aspects of the "art" of Medicine lies in communication skills between the physician and patient. It takes more than just a stethoscope, an X-Ray, or even an MRI to get to the heart of a patient's story. It is from the lines of the story that a clearer diagnosis can be made. It is by understanding a patient's values and beliefs that we can work to craft treatment options that align as closely as possible to their goals. There is an art to developing good relationships between physicians and their patients, which is vital in the practice of medicine.

#### *Interpersonal Relationships*

However as more tests become available, the art of the relationship and communication with patients is being steadily lost. Within patient encounters, doctors only elicit the patient's agenda for the visit 36% of the time [1]. Also striking was that even when the patient's agenda was obtained, patients were still interrupted seven out of 10 times at an average of 11 seconds [1]. If we stop patients that quickly, we are not listening to what they have to say. When patients are not interrupted, the meantime to describe their concerns is 92 seconds with 78% of the patients finishing their story in 2 minutes [2]. A very small minority of patients took 5 minutes to tell their stories, but in all cases, whether 2 or 5 minutes, the physicians felt that important information was provided [2]. Physicians are under time pressure with many follow-up visits in the United States only scheduled for 15 minutes. It is understandable that physicians feel like they need to jump in and direct the conversation. Yet if patients are given space to describe their concerns, they feel more listened to and physicians can gain valuable information. Good communication can improve the relationships between physicians and their patients. Having good relationships with our patients can help with a physician's overall job satisfaction [3]. Those personal connections help us stay in touch with why we entered into this profession. So listening, understanding the patient's story, and connecting with the patient benefit both patients and physicians.

How do we do this? Asking more open-ended questions can allow for a more accurate story without necessarily taking additional time. Physicians, though, worry that they will run out of time or lose track of the interview if they give patients too much space. I have witnessed this when supervising residents. One resident would start with open-ended questions during most of the new patient evaluations, until the evaluation when I was supposed to be scoring her. Then she started with very close-ended questions and led the patient through the entire interview. During our debrief, I asked what had happened. She described feeling worried that she would run out of time since she had only 40 minutes for the timed interview. However in our previous encounters when she allowed the patient to talk more freely, the interviews lasted about 45 minutes and we had a more complete understanding of the problem. For example, Haidet and Paterniti [4] describe history building rather than history taking. The authors diagram two interviews, one that focuses quickly on yes-no questions and one which allows the patient more room to tell his story. They both take about the same amount of time but the one in which the patient is allowed more space, a clearer story is provided, which also includes identifying some of the patient's underlining fears. When we address a patient's fears, they feel more listened to and supported. Overall good communication during the visits can lead to improved patient satisfaction [5].

The physician's goal in most clinical encounters is to discover what is objectively wrong and work to cure it. However, if we do not understand the patient's subjective experience of the problem, then a large portion of their concerns is not addressed. We do need to find a balance. We do not want to treat the illness without treating the individual but on the other extreme, we do not want to become so paralyzed by our patient's emotional reactions to their illness that we cannot offer them support. In ref. [6] we see the shift and balance that needs to take place in interviews so that the illness is addressed, the patient is supported, and the doctor is not overwhelmed. The author takes the reader through his encounters with different physicians as he deals with a diagnosis of Guillain-Barre Syndrome to highlight how to diagnose and treat the illness without losing track of the patient.

When my mother was ill, I experienced the distress that can come when a physician focuses on the disease but forgets the human element. My mother had been experiencing significant nausea. I was talking with her primary care physician about the next step and it was decided to pursue a brain MRI because the nausea

*Perceptive Chapter: "Are We Listening?" - Improving Communication Strategies and… DOI: http://dx.doi.org/10.5772/intechopen.105151*

was not responsive to any of the GI remedies. I still remember being in the clinic and having the physician reach out to me. She asked me excitedly if I had seen the results of the scan. I had not. She informed me, "You were right. They found a tumor in her brain." That was how I found out that my mother had glioblastoma. At that moment, I was a colleague and we had solved the medical mystery. What was forgotten is that I was the patient's daughter. I had an emotional reaction to this news. We need to not only listen to our patients but remember the humanity of our connection.

Sir William Osler said, "The good physician treats the disease; the great physician treats the patient who has the disease." Being a great physician is practicing not only the science but also the art of Medicine. We need to understand the importance of the relationship. We need to listen to and appreciate our patients' unique stories. This chapter will discuss techniques, such as active listening, consider potential impediments for developing relationships with our patients, and consider strategies to improve those relationships. The examples and many of the techniques are taken from work within the United States. While there may be cultural differences and approaches that need to be considered in different countries, many of the tools will be appropriate for all physicians. All of us can benefit from listening closely to our patient's stories, seeing them as unique individuals, and developing therapeutic relationships that can benefit both patients and physicians.

#### **2. What makes a good doctor?**

McLeod [7] seems to embody Osler's quote when he distinguishes between disease and illness. The disease is the medical aspect; it is the diagnosis. Illness is the patient's experience of the disease. This can include pain or limitations in one's life. It relates to the emotional reactions of vulnerability and fear. Illness can change how an individual looks at herself and how others look at her. The disease is only part of her story. However, we, as physicians, can forget that. In the field of eating disorders, we are careful to describe our patient as "a young woman struggling with anorexia nervosa." She is not an anorexic. This simple change in the order of words outlines that an individual is struggling with a disease. She is not completely described by it. Yet on medical rounds, patients become the "MI (myocardial infarct) in room 10" or the "asthmatic." When we talk about patients as their diagnoses, we take away their humanity. That can push physicians to treat the disease without considering the patient and their experience of their illness.

When considering what makes a good doctor, physicians tend to focus on medical skills, whereas patients focus on communication skills [8]. Defining what makes a good doctor can be difficult and may depend on the stakeholder. Yet, perhaps, we can consider some elements. Patients want physicians who can make them feel at ease, are empathetic, and can remain calm under pressure [8]. A systematic review found that patients want their doctors to have "a positive outlook on life, a good sense of humor, a well-balanced temper, and love for people" ([8], p. 400). That sounds like fairly high expectations. I remind my students that our patients want us to be engaged with and interested in what they have to say. They want us to see them as unique people and to be curious about anything in their story that could contribute to a better understanding of their illnesses and their lives. When we demonstrate caring, we earn the patient's trust. This includes following up on clues that alert us to patients' concerns [9]. Clues are hints at parts of the story that affect a patient but which he is not certain the doctor will find relevant. Patients offer these hints both verbally and nonverbally. Perhaps, they will say that there is a "lot going on." It is then up to the physician to ask about that. If we do not, then that part of the story will probably stay hidden. The patient will feel that the doctor is not interested. They will sense that we are not really listening.

We have to recognize that each patient will have a different experience with their illness. Some of this may be based on their past history—perhaps another family member or friend had similar symptoms. If that is the case, patients may worry that they also have whatever disease or outcome that befell that individual. If someone had these symptoms and was diagnosed with cancer or experienced a significant negative outcome, they may come to the physician with significant fear and a very different interpretation of what is occurring. We need to understand their fears to help them navigate the experience [4, 7]. Physicians often forget that even though we may have seen and treated this disease numerous times, this is the first time for this patient. We jump in with jargon, recommendations, and assumptions based on our past experiences. The patient, though, is facing this for the first time. They need more information, reassurance, and time to process the change in their life and view of themselves.

As physicians, we need to recognize our own feelings and limitations but also the power and influence that we have over our own patients. When we cannot cure someone, we can often feel as if we have failed. Yet many diseases cannot be cured. We only fail if we do not provide the best care for our patients or if we pull away from them as they struggle with their illness. Patients rely on us to be their guides on the rocky journey of illness and, hopefully, recovery. If we decide that we cannot cure them and pull away because we have no additional treatment to offer, we leave them stranded at the scariest part of an unknown trail. Our presence and promise to help them navigate their illness can be extremely important in the doctor-patient relationship. Patients validate this truth. While they value a physician's medical knowledge and expertise, patients actually appreciate humanistic characteristics more. In scoring of what makes a good doctor, being scientifically proficient came in third after sensitivity to emotion, which included listening skills, and positive personality traits [10]. We need to consider that "Communication is the most common 'procedure' in medicine" [11, p. e1441]. So how can we develop these skills?

#### **2.1 Active listening, clues, and agendas**

There are three elements to consider when thinking about communication informativeness, interpersonal skills, and partnership building [11]. What we are trying to do is connect with our patients, provide the information that they need to understand their illness and treatment options, and work to form a partnership to navigate the terrain of the illness and treatment. When we think about this relationship it is helpful to remember that "there are two types of patient needs to be addressed during the medical interview: cognitive (serving the need to know and understand) and affective (serving the emotional need to feel known and understood)" [11, p. e1442].

When engaging with patients we need to actively listen, which is much more than just staying quiet and paying attention. Although as we already discussed, physicians even have difficulty with the staying quiet part—interrupting their patients early in the discussion. As ([12], p. 1053) points out, "Active listening is a difficult discipline. It requires intense concentration and attention to everything the person is conveying, both verbally and nonverbally." We begin to realize how challenging this can be when we consider how we often participate in conversations. Typically, individuals half-listen to a story and spend much of their mental energy thinking about what they are going to say when it is their turn. Or we find ourselves thinking about what we need to do next or reconsider a past decision. We are there in the conversation but not completely there. We also are not usually considering

#### *Perceptive Chapter: "Are We Listening?" - Improving Communication Strategies and… DOI: http://dx.doi.org/10.5772/intechopen.105151*

what the other person is not saying. We do not watch for signs of discomfort, which can indicate when someone is holding back uncomfortable information. Yet those are the exact conversations that we need to be having with our patients.

For example, Robertson [12], defines some roadblocks that can occur when we are trying to actively listen. One is judging or evaluating the other person's perspective. Our role is not to decide if the complaint is as detrimental as a patient is describing. Maybe it would not be so devastating for us but we need to listen to their experience. We often jump in and offer solutions before we completely understand our patient's complaints. If the conversation is uncomfortable, we try to divert the discussion or reassure the patient, which may seem like a good thing but if it is done too early, it prevents the patient from fully being able to discuss their concerns. Active listening includes demonstrating our attentiveness through our body language and facial expressions, which can be harder in the current time with the need for masks in the healthcare setting. We need to consider our questions. Yes or no questions often become the staple of physicians' language as we work to zero in on positives or negatives in the review of symptoms. This, though, hampers the patient in telling their story. What is more helpful in active listening is "door openers," such as encouraging the patient to tell you more about the problem, how it is affecting their life, anything that they have tried to solve the issue, and what they are most concerned about [12]. One reason to explore these questions is that "most patients who experience illness symptoms develop an explanatory model" ([13], p. 222). Even before they enter our offices, patients have started to think about their symptoms and have often developed an explanation based on their frame of reference. For example, if they have a persistent cough and know someone who passed away from lung cancer that can be one of their main worries, or in current times, they may fear having COVID-19. If we do not discover what they are truly worried about, our reassurances will not be believable.

The authors [13] analyzed recorded interviews between students and patients and followed up with patients to understand potential clues being offered in the interviews. These clues if pursued provided improved insight into a patient's concerns. The clues often included an expression of feeling—such as describing being bothered or worried; attributing a concern to someone else, such as a family member, which allowed the patient to slip the uncomfortable issue into the conversation, or vividly describing the symptoms. Another avenue for patients to convey clues was to offer their own explanations about a symptom. This made it clear that they had been thinking a lot about the issue and were trying to figure things out. They were looking for a physician to either confirm or deny their worries. Clues are fairly common in medical interviews. Clues occur in 52% of primary care visits, and 53% of surgical visits with a mean number of clues of 2.6 per visit in primary care and 1.9 clues per visit in surgery [14]. Over half of our patients are offering clues and if we follow up on them, we can have a more meaningful and impactful conversation and connection. Often physicians do not follow up on the clues or utilize active listening because there is a fear that something will be brought up that will then extend the visit. However there is evidence that the opposite occurs—following up on clues not only does not make visits longer, but in some cases, it can shorten visits. In primary care visits that included at least one clue, visits were longer when the clue was not followed up on as compared with visits in which physicians demonstrated a positive response to the clue—for primary care mean visit time was 20.1 minutes if the clue was not followed versus 17.6 minutes if a positive response was given; for surgery, visits were 14 minutes when the clue was not followed up as compared to 12.5 minutes when it was [14]. In another study, patients who were asked open-ended questions took only 16 additional seconds to present their symptoms (27.1 seconds versus 11.3 seconds) than patients who were asked closed questions [15]. In ref.

([13], p. 226) we are reminded that "while the use of active listening carries certain challenges, identifying the patient's real concerns usually results in a new level of understanding of the patient, increased satisfaction for both patient and physician, and improved medical management."

Visits typically focus on the physician's agenda—to identify the illness through a biomedical lens and offer treatment. For example, Levenstein et al. [16] describe the importance of incorporating not just the physician's agenda in the session but also the agenda of the patient. Discovering the patient's agenda is not always as simple as asking what they want to talk about that day but also watching for the clues described above that hint at deeper concerns. The physician's agenda is to be able to understand and explain the patient's illness by identifying and categorizing the patient's disease. The patient's agenda is to come to an understanding of the illness but to also be able to express his/her feelings, expectations, and fears. Visits are more successful when both agendas are addressed and any conflict or different expectations are negotiated and discussed. This can be challenging, at times, especially if symptoms cannot be easily explained or answered. Both parties may feel frustrated but the patient will feel abandoned if the doctor does not delve into the emotions and concerns related to the illness. If a physician does not explore or consider the patient's narrative, increased conflicts can occur [17]. In these situations, especially if the physician feels that the patient is not agreeing to the recommendation, they tend to become more coercive rather than interactive. "Physicians must always take care to avoid considering their narratives as 'the truth' and the patient's narrative as 'fiction' if it happens (as it often does) to disagree with that of the physician" ([17], p. 14). One way to obtain the patient's narrative is through active listening. We then need to respect their narrative.

#### **2.2 Nonverbal communication**

One way that respect is conveyed is through our nonverbal communication. It is vital to ensure that we do not shut the conversation down before it has even had a chance to get started. This can happen through initial nonverbal signs. When I was in the hospital after having delivered my second child, I remember when the pediatrician came to visit me. He barely entered the room, stood with his arms crossed in front of him, and asked if I had any questions. I did not—this was my second child and my husband was a pediatrician—but even if I had wanted to ask any questions, his stance stopped the conversation before it could even begin. There was clearly no invitation to express concerns or ask questions.

Nonverbal communication includes eye contact, head nods and gestures, position, and tone of voice [18]. Eye gaze, in particular, demonstrates engagement and listening to the speaker [15]. Consider how you are placing yourself in the room—is the computer between you and the patient? Are you staring at the screen instead of making eye contact with the patient? If you need to turn away from the patient to check something on the computer, clarifying the action can be helpful in maintaining the connection—such as identifying that you need to check a lab value or medication to help further understand the patient's story [15]. Too often we interact more with the computer rather than with the patient. Sitting versus standing makes patients feel that the physician is more caring and compassionate and has spent more time with the patient [18]. Often the visit is not longer if the physician sits, but it can feel that way [19]. The physician is there in the moment with the patient and not standing with one foot out of the door.

Nonverbal immediacy (being clearly present and connected in the session) improves patient satisfaction [20]. Through our facial expressions and body stance, we need to be present and not dismissive. We need to communicate engagement

*Perceptive Chapter: "Are We Listening?" - Improving Communication Strategies and… DOI: http://dx.doi.org/10.5772/intechopen.105151*

and interest, not detachment and annoyance. If a patient has a worry, we need to acknowledge it and not just dismiss it. If a patient feels that their concerns were seen as frivolous or annoying, they will not want to ask us or other physicians about them for fear of getting the same response. Our communication strategies, especially the way we nonverbally express our reactions, can have huge impacts on the doctorpatient relationship.

#### **2.3 Dealing with emotions/biases**

Another tool that helps with the relationship is the physician's emotional regulation [20]. Patients want their physicians emotionally engaged but with regulated emotions so that they do not overwhelm the interview. We need to be aware of our emotions so that they do not leak out in nonverbal responses or prompt us to lose our professional composure with our patients. We need to be aware of our biases so that we do not unintentionally (or intentionally) alienate our patients. We often define patients as "difficult" when they engender too much negative emotion in us. "For example, the angry patient can irritate a doctor so intensely that he will become angry in return, avoid contact with the patient, or even occasionally refuse treatment" ([21], p. 1045). Certainly physicians need to keep themselves safe when dealing with angry patients but tools can help defuse some of the emotion. These include trying to understand what is fueling the negative feelings. I have worked with patients whose anger stemmed from feeling a loss of control from the illnesses and proposed treatments. When we worked to understand their concerns, their anger lessened, they were able to engage in the treatment, and eventually become more motivated to pursue recovery. Another tool, "My go to technique that I train folks on is learning to soften their tone and the volume. While it does not always work, generally people want to hear what is being said (and when we talk softly, it often adds an air of importance to what we are saying). More often than not the person that is escalated will match your tone…" [D. Schwartz, personal communication, August 16, 2021].

At times we can recognize a patient's emotions by the emotions that they generate in us. When we start to feel angry, it can be a clue that the patient is experiencing that emotion as well. There are ways to try to connect with a patient's emotions. Reflection can be useful—telling the patient what you are noticing. For example, if you sense the patient is feeling sad, stating that fact can help deepen the conversation. This can be more effective than asking a question. If a patient is sad, asking them why can lead to the response that they do not know why. We often do not know why we feel a certain way. But making the observation that someone is sad and reflecting back as they expand on their thoughts can help the patient and physician get to a deeper place of understanding [21]. It is important to legitimize their feelings and provide support. It can be helpful to provide respect for what the patient is doing well—such as coming in to talk about the symptoms or any other tools they have used to try and help themselves. This provides a perspective for the patient that they can be successful as they continue to navigate the situation [21].

Other challenges and increased emotions can come from misunderstandings. Physicians tend to underestimate patients' pain and overestimate patient education [22]. Evidence has been shown that physician bias can enter into this with physicians sometimes underestimating the pain of African-American patients in particular [23]. If we leave a patient in pain, clearly this is going to interfere with our relationship. If we overestimate a patient's level of understanding that can leave them feeling confused and with unanswered questions. These challenges can compound each other. One study demonstrated that physicians' styles of communication were affected by their perceptions of patients. Physicians were more

patient-centered, less contentious, and more positive with patients whom the physicians felt to be better communicators [24]. In this study, physicians were more contentious with black patients than with white or Hispanic patients. Within this study, we can see some of the systemic racism in healthcare that has been identified in the United States. We also see that the patients who probably need clearer communication from the physician and more engagement in the process are those who are on the receiving end of more negative interactions.

Another challenge is when patients and physicians have very different thoughts or perceptions of what might be happening but do not fully discuss their beliefs. In this situation, assumptions can be made. For example, this can occur when a physician believes that part of the patient's symptoms is related to an emotional component. For many illnesses, a psychological component can exacerbate the physical symptoms. Examples can be gastrointestinal issues, such as irritable bowel syndrome or headaches to name just a couple of commonly occurring conditions. If the physician suggests that it might be helpful to see a therapist or psychiatrist, often the patient hears that the physician believes this is all in their mind. They feel like their symptoms are not being taken seriously. Other issues maybe when there are clear stressors in the patient's life but they seem to be discounting them—describing that they are not stressed at all. Individuals with lower back pain discussed how validation of the extent of their suffering helped with the doctor-patient connection [25]. One concern of patients is that their suffering will not be recognized or it will be invalidated. If that happens, communication hits a wall. Patients will not want to share further experiences or ask additional questions because they worry that they will not be believed. In ref. [26] there is evidence of other barriers, such as the patient introducing unexpected resistance to a suggestion or evidence of verbalnonverbal incongruity. In this case, the patient can verbally say that they agree with the doctor, but their nonverbal language may suggest that they do not accept the doctor's explanation and won't follow up.

So how can we navigate some of these barriers? One example of how a physician can navigate the challenge of unexplained illness or pain is to explain that with our current tools, he cannot find something physically wrong at this time. That does not mean something is not there. We have seen symptoms that were previously dismissed now being understood as Chronic Fatigue Syndrome. Just because we cannot figure out what is wrong now, does not mean there is not a physical issue. One way to approach this is to acknowledge the patient's physical complaints and discuss plans to work on them but consider how to move forward if the physical symptoms continue but cannot be more clearly diagnosed. The physician can acknowledge that the physical symptoms may not be completely resolved in the near future, or maybe ever. At that point, the discussion can turn to how the stress of these symptoms is affecting the individual. The discussion of therapy can be used to empower the patient to find additional ways to handle their symptoms while you both continue to look for a source or a cure. If they are able to decrease some of their stress, that might help with the physical illnesses.

Sometimes good communication means finding a way to ally with your patient, merge your goals and suggest options in ways that will be agreeable to him or her. It is important to separate the problem from your patient. For example, if we work with patients who struggle with fatigue, we try numerous ways to try improve the symptoms and yet they are still fatigued, it can be frustrating to both the patient and physician. If in the middle of that frustration, the doctor blurts out, "I cannot find anything wrong physically. It must be stress. You need to see a therapist." How will the patient feel? We need to recognize that our frustration is not with the patient, it is with the fact that we cannot seem to fix the problem. We cannot find an easy cause or explanation and so it feels frustrating. The patient, though,

*Perceptive Chapter: "Are We Listening?" - Improving Communication Strategies and… DOI: http://dx.doi.org/10.5772/intechopen.105151*

will hear this as a rejection. They will feel blamed for their symptoms. They will feel not believed. We need to remember that both the patient and physician can feel frustrated when a cure cannot be easily found. We are not frustrated with each other; we are frustrated with the situation. This brings us back to how to approach this conversation—with compassion and empathy. "I can tell that it is frustrating to feel so tired all the time. I am also frustrated that we cannot find a clear reason and solution. We will keep trying to understand what is happening. In the meantime, it might be helpful for us to consider some additional tools. Sometimes when individuals are struggling with physical symptoms for so long, they can feel stressed by the situation. This can make the fatigue worse. Also being so tired can sometimes make it hard to keep up with everything that you want to be doing in life. Talking about how to cope with that frustration can be helpful. So while we work together on the physical side, how about if I get you the name of a therapist who can help you navigate this challenge?" It might take a few times of suggesting the option to get buy in. But it is important to communicate belief in your patient's views, support for their struggles, and work to align with them to find additional tools to improve their health.

#### **2.4 Understanding personality disorders, boundary issues, and trauma-informed care**

Patients who struggle with personality disorders can often elicit intense emotions. This can make communicating effectively with them in medical settings difficult. At times, healthcare workers might try to avoid these individuals because of the difficult emotional encounters. Unfortunately, that can often spiral the difficulties. If a patient is scared and angry because of his illness or the lack of answers and yells at individuals who approach him, staff will try to avoid him as much as possible. It is only natural—none of us like getting yelled at or dealing with anger. Yet when we distance ourselves from this patient, he becomes even more angry and scared and we get stuck in this cycle. Ways to try to intervene are similar to some of the techniques above. We need to stay calm, we need to provide information in clear and simple terms. We can let the individual know that his anger is making it hard for people to do their jobs. If he is trying to get answers, yelling at staff is not going to help with that goal.

For patients who struggle with borderline personality disorder (BPD), they can often get stuck in anxiety and sadness [27]. Individuals with BPD often have their anger triggered by anxiety. This can be important to remember as physicians. If we are dealing with someone who is extremely angry, we need to consider if they are reacting that way because of overwhelming fear. How can we defuse the anger? As above, through using a calm voice, ensuring that they and everyone are safe, and suggesting that maybe part of why they are so angry is that this situation feels overwhelming and scary. Try to help them talk through their fears and the next steps. Reassure them that the staff will work to help support them through this challenging time. Helping to decrease their intense emotions can help defuse the situation and also decrease their intense feelings. For example, Nisselle [28] reminds us to not think of these individuals as difficult patients but to consider more than it is a difficult relationship or discussion. This makes the difficulty more at the moment and allows us to think about how we can get the discussion back on track. If we label the patient as difficult then we do not see hope for any change.

There are certain techniques that can help individuals who struggle with personality disorders. Reference [29] provides a thoughtful and excellent guide. He looks at the three types of personality disorders and offers suggestions on how to deal with them. Cluster A, which includes paranoid, schizoid, or schizotypal, are individuals who are often not comfortable with interpersonal interactions, they stay by themselves and are often fearful, believing others are out to harm them. Some of the tools that we use to try and create a close relationship, will often make these patients even more uncomfortable. Instead, we need to recognize that it was difficult for them to even reach out for help. We need to maintain a professional demeanor, use simple language, and not challenge any odd beliefs, but work to help them navigate the medical tests that are necessary for their treatment. For Cluster B, which includes antisocial, borderline, histrionic, and narcissistic, we need to recognize that our emotions will often be stirred up by these individuals. At times, we will feel manipulated. Often they will either manipulate us into feeling their intense emotions or try to use our emotions to get what they want from the situation. For some, this manipulation is intentional (typically antisocial individuals) and at other times, it is unintentional but is a byproduct of their personality disorder. For individuals with borderline personality disorder, they feel things so intensely that they can engender those feelings in us. Sometimes the first way to handle the situation is to identify what we are feeling and question whether that is how they are feeling in the moment—angry, scared, overwhelmed. Again with these patients, it is important to create a professional distance, recognize the need, and set limits as appropriate. Limits will be tested and it is always important to consider, are we setting limits to help maintain our professional relationship with the patient or as a punishment because we have felt taken advantage of, either through requests or through the emotions that they have stirred up. It can help when considering requests or limits to thinking about whether you would do this for all of your patients. Often individuals struggling with these personality disorders will feel entitled and will push for requests that are not reasonable in the situation. Limits need to be set because they will help maintain the professional nature of the relationship and allow you to treat the patient. They should not be set in a moment of anger or frustration. Individuals with these personality disorders are probably the most difficult to work with and engender intense feelings in healthcare professionals. It is important to recognize that their behaviors are part of their personality—they cannot often recognize them or change them. It can help to breathe, to take a step back if needed, and to think through your responses. Individuals with a borderline personality disorder often evidence black and white thinking. Things or people are either all good or all bad. If you are the best doctor ever, appreciate it but do not get lulled into that belief. Keep a professional distance and work to provide care to that patient as you would to any other client. At some point, in their eyes, you may be the worst doctor ever because you have disappointed them in some way. You might not even know how this happened. Again, keep a professional distance and work to provide the care you would give to any other patient. None of us are all good or all bad even if we are made to feel that at the moment. Cluster C includes avoidant, dependent, and obsessive-compulsive individuals. For these patients, performing complete history and physicals so that you can provide reassurance and also complete explanations can help with reassuring them.

Individuals who struggle with personality disorders can often try to influence a closer relationship with a physician. It is important for physicians to recognize and set clear boundaries with patients. This does not mean that we have to be distant and uncaring but we need to recognize our role within the situation. "Boundaries define the expected and accepted psychological and social distance between practitioners and patients" ([30], p. 2569). This includes recognizing that we are their physicians and not their friends. It can relate to self-disclosure. Self-disclosure can be helpful if it is used to benefit the patient but not if it is to help unburden the physician. While many times self-disclosure helps with communication—to perhaps encourage screening tests by sharing a similar

#### *Perceptive Chapter: "Are We Listening?" - Improving Communication Strategies and… DOI: http://dx.doi.org/10.5772/intechopen.105151*

situation—there are times that self-disclosure is used more to unburden the physician rather than to help the patient [31].

We need to recognize and consider how our actions might be perceived by our patients and others—are we giving more time to one patient, willing to see them in a different location, or stepping over boundaries, which will muddy the doctor-patient relationship and confuse or harm our patient? [30] Recognizing the importance of boundaries can be especially important when working with individuals who have, perhaps, experienced trauma and is part of the recognized technique of performing trauma-informed care (TIC) [32]. For individuals who have experienced past trauma, their boundaries have been violated. Often it can be that a person that they trusted harmed them through emotional, physical, or sexual abuse. This can make it hard for individuals to trust. When considering boundaries and TIC, it can be helpful to consider how to provide a place of safety both physically, a private room where the person feels free to talk, and emotionally, helping the individual understand what is going to happen next in the encounter so that know where they are going to be touched and why [32]. Part of understanding boundaries is understanding the power differential between patients and physicians, especially as our patients are sitting there in a hospital gown, and not taking advantage of the power that we as physicians hold over our patients. Sometimes this power allows us to invade a patient's space even when we do not realize that we are doing it. We need to be aware of the situation, such as are we allowing the patient to stay as covered as possible while we perform the procedure or understand that our touch might trigger past traumas.

Sometimes in interviews physicians hold back from perceived boundaries that actually limit the connection with a patient and the level of understanding of their issues. In a fourth-year elective in the Department of Humanities, I worked with a number of medical students. In a standardized case, they had to work with a patient who was being seen for hypertension but had a number of beliefs and a past history that affected her willingness to pursue treatment. Within the case, if the student asked questions in a way that made the patient feel comfortable, she would provide more backstory. If they did not pick up on any of the cues that she provided, she did not provide that part of the history. In discussing the encounter with the students after the session, many noticed the cues by the patient that indicated that there was more to the story—looking anxious and fidgeting. When we discussed why they had not pursued these cues and asked the patient more about her past social history or concerns, they related that they did not want to be seen as too "nosy." We need to respect the patient's boundaries and discomfort but we also need to be able to open the space and ask the necessary questions. If patients do not want to provide their history, they will usually say that they do not want to talk about it. That is a clear boundary. If, though, they are providing hints through their actions that there is more to the story, they are often waiting for us to give them the space to discuss their concerns. If we do not provide that space or seem willing to talk about a topic, then they will feel that they shouldn't bring it up. We need to be "nosy" at times. We need to ask if there are other concerns. Is there more that they are worried about or something that they are finding hard to discuss? A calm and interesting persona lets our patients know that we are not asking these personal questions just to satisfy our curiosity but we are asking them because they seem to be on the patient's minds and affecting their lives.

#### **2.5 Suggestions**

While each of us has our own communication style and comfort within interpersonal relationships, there are some tools that can be taught to help improve

communication when you are working with patients. First is to keep in mind that we may need to let the patient tell their story of why they are there. Instead of interrupting in the first few seconds, as physicians tend to do, let the patient describe their concerns. In typically within 2 minutes or so, they will have told you their story [33]. One can see that this will not extend the interview by much time, but it will allow you to understand what is really on your patient's mind. Patients follow the style of their doctors. If the doctors frame questions very narrowly from the beginning of the encounter, then patients try to follow those unspoken guidelines and offer limited answers. I often advise trainees to consider the interview as a funnel—start broadly and ask questions that give the patient the space to tell their story. Then at the end, you can narrow your questions to obtain more specific details if they are needed. When conducting the session, it can help to record facts about the patient's personal story—if they have kids or are heading on a vacation. Using that in the next visit can help to foster the relationship. It can help with patient satisfaction [33]. Individuals feel seen as a person, with interests and a life outside of the illness.

Mnemonics and models are offered below that focus on how to ensure that active listening and other skills are included in the interview. While there are other models available, these offer ways for physicians to consider their interviews and if they are listening to and engaging their patients. Using skills from these models can help physicians improve their communication and, thereby, their relationships with their patients.

For example, Nisselle [28] talks about the 4 'E's'. Did you **engage** the patient? Did you start the conversation off in a collaborative tone? The next E is **empathy**. Does your patient feel seen and heard? Do you truly understand the level of their suffering? Third is **education**. Has the patient been given enough information to understand your recommendations? The final E asks whether you have **enlisted** your patient. Have you worked to align your goals to that of your patient so that you are on the same team—that your patient understands your plan and is willing to try it. Education and enlisting are so important but often not included to a necessary extent. For example, when discussing discharge plans, physicians believed that 89% of patients understood the potential side effects of their medications, but only 57% of patients reported that they understood the risks. Physicians believed that 95% of patients understood when to resume normal activities, while only 58% of patients reported that they understood [34]. How can we enlist patients to complete the treatment plan if they do not understand it?

In ref. [35], a great mnemonic is presented to help physicians recognize the individual natures that both we and our patients bring to our encounters. **A** stands for **I Am**. This focuses on meaning—what is important in the patient's life? How are you finding meaning in your work with the patient? **B** stands for **I belong**. This focuses on the sense of community—for the patient, whom can they turn to for support; for the physician, what resources are available, are there others that can help in this care? **C** stands for **I can**. For the patients, they want to know if they have the capacity to get better—what can they do to affect the outcome; for physicians, we want to consider what we can do to positively influence this patient's health. **D** stands for **I dread**. This is what the patient is worried about. As a physician, our worry is about whether we can make our patients better. **E** stands for **I exist**. This is different than the existence of the individual person but focuses more on the existence of the physical body—the patient wants to know what is wrong. The physician needs to consider the biomedical explanation of the illness and what care to provide. This prompt can take us from what is important in our work—the overall recognition of the person, which has to be our paramount concern to the level of determining what is wrong. We need to work from the global recognition of the person as a whole

before we dive into treating what is wrong on a cellular level. Too often physicians work from the opposite direction—they focus on the specific illness and ignore the person who is struggling with the symptoms, emotions, and influences of the illness on their life.

One study in Southeast Asia looked at the Greet-Invite-Discuss technique and found that it led to a more partnership-oriented and culturally sensitive communication in primary care settings when physicians were working with patients with chronic illness [36]. The technique outlines: Greet—initiate and maintain a "familial" relationship with patients; Invite—explore the patient's story; Discuss—use negotiation and shared decision-making tools to develop a plan [37]. When using the framework, improved blood pressure and blood glucose control were demonstrated as compared to a more doctor-centered, list of questions approach [36]. As we see with these techniques, patients feel respected, seen as a whole person, and listened to. When considering the relationship with the patient, I often tell students to speak with the individual as they would want someone to talk with one of their family members. This does not mean stepping over boundaries as we discussed earlier in this chapter but treating the individual with respect, seeing them as a person who is important to others, and understanding them as someone's child, mother/ father, brother/sister, cousin, wife/husband or friend. How would you want your loved one treated by a physician? That is the way we need to talk with our patients.

The Four Habits Model describes an interrelated set of skills, which include investing at the beginning of the interview, eliciting the patient's perspective, demonstrating empathy, and investing in the end [38]. "The goals of the Four Habits are to establish rapport and build trust rapidly, facilitate the effective exchange of information, demonstrate caring and concern, and increase the likelihood of adherence and positive health outcomes" ([38], p. 79). In the initial habit, the authors focus on creating a welcoming connection so that the patient knows that they have our full interest and attention (remember active listening?). They recommend using open-ended questions to elicit the patient's concerns and recommend that you plan out the visit with the patient. This last step allows both the physician and patient to include items that will be important to the agenda of the day's visit [38]. Within the use of open-ended questions, they offer ideas of how to get more information about any concern—using silence, nonverbal signs of interest, and asking the patient to "tell me more" about any concern that they have raised. This allows the physician to understand the patient's underlying concerns and what brought them in. The physician might have their agenda for the visit but if they do not address the patient's actual concerns, the patient will leave the visit feeling dissatisfied and not heard. The reader can see how these skills flow together because the second habit is to elicit the patient's perspective. It has already been started in the beginning as the physician creates rapport with the patient and starts asking open-ended questions about the reason for the visit. In this habit, as the physician gets more of the story, he/she works to understand how the concern impacts the different areas of the patient's life. They work to understand what the patient has already tried and what worries they have about the symptom. By understanding the hidden worries, perhaps worries they have already linked to the symptom, the physician and patient can more clearly discuss the symptoms. Any reassurance will be more believable if the patient's actual fear has been discussed—for example, if they have a headache and are worried about a brain tumor, getting the fear out into the conversation can allow the physician to address it more clearly. The third habit is demonstrating empathy, which of course cannot happen in just one moment but needs to be present within the entire interview. This is why the authors discuss how these skills are interconnected. By demonstrating empathy, the physician conveys a willingness to understand a patient's emotions related to their concerns. Often physicians

side-step this because feelings are difficult. It is easier to focus on trying to identify the cause of pain rather than address the emotional pain of the patient—the fear of what is causing the pain, the sadness at the loss of activity related to the pain, and the anger at being the victim of pain. The fourth habit is investing, in the end, to try and develop a plan that the patient is comfortable with to help ensure adherence to the plan [38]. The physician can develop the best plan possible but if the patient is not on board with the diagnosis, recommendations, and next steps, the chance of them complying is very limited. These four habits help physicians and patients work together to improve communication and the overall visit and partnership.

An expanded four habits model improves work with patients who struggle with emotional distress [39]. The authors work with the four habits model but focus on skills to allow for more in-depth exploration of the emotional concerns of the patient. This means being sensitive to and willing to explore the patient's emotions and being empathic to these emotions. Exploring more fully the patient's perspective and understanding so that both patient and physician have improved insight. The physician assesses the patient's resources and strengths and uses this information to empower the patient and focuses on strategies for coping with the illness. Both the Four Habits and Expanded Four Habits are patient and relationship centered. Rather than using a checklist of symptoms, the interaction is a focused on patient's fears based on their history. Yes, checklists help us identify what the illness might be and the next steps but if we do not establish a good relationship with our patients, there is a good chance that they will not follow through with the recommendations.

The expanded four habits model uses skills from ref. [40], which identified six skills that are important in patient-centered interviews and care. The first is exploring a patient's emotions—this can occur by staying silent and giving the person more space to talk. Or it can happen by reiterating a patient's described emotion— You have felt overwhelmed?—or by asking them to tell you more. [41] describes silence as a particularly useful tool, which can be easily introduced into a session but can feel overwhelming to the physician. The author describes that typically when a patient stops talking, the physician jumps in faster than even a second. Sometimes the patient might not even be able to complete their thought before the physician jumps in. Waiting even 10 seconds after the patient has stopped speaking can lead to vital information. Patients will continue talking to fill the space and in these moments can express what is really on their minds. Ten seconds of silence will feel long but that small space of quiet can allow the patient a chance to express concerns. The second skill is to respond empathetically to the patient—this can happen by acknowledging that something must be very hard for them or expressing pleasure in something good that has happened to them. The third skill is exploring the patient's perspective to see what thoughts they might have as to what is causing or contributing to the problem. They might turn it back on you and say that you are the doctor. But if they have been living with this symptom, they might have their own theory or worry. This skill is to work to understand that. The fourth skill is to help provide insight, perhaps looking at vicious cycles, such as when the patient becomes anxious about the pain, it can cause an increase in the pain, which continues the cycle. The fifth skill is to explore resources of the patient, what have they done that has helped, to help identify their strengths, and to explore outside supports. The sixth skill looks at improving coping. In this skill, the physician builds on the strategies that the patient has been using, which have been, at least, somewhat successful.

In all of these models, physicians are encouraged to invest at the beginning of the interview by developing rapport and eliciting the patient's concerns. Within these frameworks, there is a focus on obtaining the patient's perspective—working to understand how the current concerns are affecting his/her life. [41] discusses that

*Perceptive Chapter: "Are We Listening?" - Improving Communication Strategies and… DOI: http://dx.doi.org/10.5772/intechopen.105151*

paraphrasing what the patient said can help us understand their perspective and help with clarification if we have misunderstood something. You can use the phrase, "So what I hear you saying is…" and see if you have heard the patient correctly. Within these interviews, it is important to demonstrate empathy, both verbally and nonverbally. As we have discussed in this chapter, nonverbal behaviors can have a huge impact on an interview. Physicians need to also invest in the end, making sure that the patient understands and agrees with the treatment recommendations. The skills involved in these frameworks include being sensitive and exploring the patient's emotions; exploring the patient's perspective and understanding; assessing the patient's resources and strengths; and promoting empowerment by focusing on coping. These methods may seem overwhelming but they can improve communication. Our goals must include understanding our patients' concerns and engaging them in the treatment plan.

The ALERT Model works to connect with questions that are asked to explore how patients feel about their healthcare and providers. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) in the United States "…assess how well the physician listened carefully to the patient, how often the physician explained things understandably, how often the physician showed respect for what the patient said, and how often the physician spent enough time with the patient" ([42], p. 70). The ALERT Model works to remind physicians about these assessments and how to ensure that these techniques are part of their interview style. The model stands for: **A**lways **L**isten carefully; **E**xplain things understandably; **R**espect what the patient says; Manage **T**ime perception [42].

While these models explain what a physician needs to do in the sessions, it is important that the physician stays in the moment. If the physician focuses on whether he/she is following the exact guidelines and using the precise phrasing of questions, then they are missing the point of these suggestions. The guidelines offered through these models and in this chapter are to help the physician be more present and engaged with the patient. It is important to connect at the moment and not be distracted by wondering if you have, for example, paraphrased enough or managed time perceptions.

Within these models, managing time perception relates to time within the visit. Even simple things, such as apologizing if you have kept a patient waiting, can help at the moment to improve the relationship and improve communication. Patients often feel as if a visit is longer if the doctor has sat down with them and maintained good eye contact. Glancing at his watch or looking hurried can cause the patient to feel as if not much time was spent with them. Time perceptions are also important to remember related to how doctors and patients define time in general. In ref. [43] the author describes that physicians who have become patients start to understand some of these differences a little more clearly. Physicians, once they had been patients understand that when anxiety or uncertainty hangs over a patient's head, it can affect the sense of time—lengthening it as one suffers and struggles with the unknown. Time is no longer an objective measurement but subjectively feels much longer and more unsettling. Helping patients understand and navigate the process can be an important part of the relationship so that the patient feels supported and understood.

#### **3. Conclusion**

When we practice medicine, we need to consider whether we are treating the illness or the patient. This chapter focused primarily on the goal of listening to our patients, working to hear their unique stories, and being open to the different emotions or fears that may accompany illness. Many of these suggestions can help physicians develop deeper connections with our patients. Those connections can help our patients feel more understood and cared for. They can help us find more satisfaction in our work. That satisfaction can benefit us all—patients and physicians. We need to not only be good physicians but also work to be great physicians. We need to treat the patient, not just the illness.

## **Conflict of interest**

The author declares no conflict of interest.

## **Thank yours**

I must thank all the patients, students, and physicians whom I have worked with. They have shared stories of both good and challenging communications. It is through them that I have developed more of an appreciation for the "art" of medicine and the strength of interpersonal relationships between physicians and their patients.

## **Author details**

Martha Peaslee Levine Penn State College of Medicine, Hershey, PA, USA

\*Address all correspondence to: mpl12@psu.edu

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Perceptive Chapter: "Are We Listening?" - Improving Communication Strategies and… DOI: http://dx.doi.org/10.5772/intechopen.105151*

#### **References**

[1] Ospina NS, Phillips KA, Rodriguez-Gutierrez R, Castaneda-Guarderas A, Gionfriddo MR, Branda ME, et al. Eliciting the patient's agenda-secondary analysis of recorded clinical encounters. Journal of General Internal Medicine. 2018;**34**(1):36-40. DOI: 10.1007/ s11606-018-4540-5

[2] Langewitz W, Denz M, Keller A, Kiss A, Rüttimann S, Wössmer B. Spontaneous talking time at start of consultation in outpatient clinic: Cohort study. BMJ. 2002;**325**(28):682-683

[3] Deng S, Yang N, Li S, Wang W, Yan H, Li H. Doctors' job satisfaction and its relationships with doctor-patient relationship and work-family conflict in China: A structural equation modeling. The Journal of Health Care Organization, Provision, and Financing. 2018;**55**:1-11. DOI: 10.1177/00469580 18790831

[4] Haidet P, Paterniti DA. "Building" a history rather than "taking" one: A perspective on information sharing during the medical interview. Arch Int Med. 2003;**163**:1134-1140

[5] Weber AS, Verjee MA, Musson D, Iqbal NA, Mosleh TM, Zainel AA, et al. Patient opinion of the doctor-patient relationship in a public hospital in *Qatar*. Saudi Medical Journal. 2011;**32**(3):293-299

[6] Ennis JH. The physician-patient relationship: A patient-physician's view. Canadian Family Physician. 1990;**36**:2215-2220

[7] McLeod ME. Doctor-patient relationship: Perspectives, needs, and communication. The American Journal of Gastroenterology. 1998;**93**(5): 676-680

[8] Steiner-Hofbauer V, Schrank B, Holzinger A. What is a good doctor? Wiener Medizinische Wochenschrift (1946). 2018;**168**:398-405. DOI: 10.1007/ s10354-017-0597-8

[9] Hillen MA, de Haes HCJM, Stalpers LJA, Klinkenbijl JHG, Eddes EH, Butow PN, et al. How can communication by oncologists enhance patients' trust? An experimental study. Annals of Oncology. 2014;**25**:896-901. DOI: 10.1093/annonc/mdu027

[10] Borracci RA, Álvarez Gallesio JM, Ciambrone G, Matayoshi C, Rossi F, Cabrera S. What patients consider to be a 'good' doctor, and what doctors consider to be a 'good' patient. Rev Med Chile. 2020;**148**:930-938

[11] Levetown M. Communicating with children and families: From everyday interactions to skill in conveying distressing information. Pediatrics. 2008;**121**:e1441-e1460. DOI: 10.1542/ peds.2008-0565

[12] Robertson K. Active Listening: More than just paying attention. Australian Family Physician. 2005;**34**(12): 1053-1055

[13] Lang F, Floyd MR, Beine KL. Clues to patients' explanations and concerns about their illnesses A call for active listening. Archives of Family Medicine. 2000;**9**:222-227

[14] Levinson W, Gorawara-Bhat R, Lamb J. A study of patient clues and physician responses in primary care and surgical settings. Journal of the American Medical Association. 2000;**284**:1021-1027

[15] Mikesell L. Medicinal relationships: Caring conversation. Medical Education. 2013;**47**:443-452

[16] Levenstein JH, McCracken EC, McWhinney IR, Stewart MA, Brown JB. The patient-centered clinical method. 1. A model for the doctor-patient interaction in family medicine. Family Practice. 1986;**3**:24-30

[17] Boyd JW. Narrative aspects of a doctor-patient encounter. The Journal of Medical Humanities. 1996;**17**(1):5-15

[18] Gupta A, Harris S, Naina HV. The impact of physician posture during oncology patient encounters. J Canc Educ. 2015;**30**:395-397. DOI: 10.1007/ s13187-015-0807-2

[19] Swayden KJ, Anderson KK, Connelly LM, Morna JS, McMahon JK, Arnold PM. Effect of sitting vs. standing on perception of provider time at bedside: A pilot study. Patient Education and Counseling. 2012;**86**(2):166-171

[20] Kafetsios K, Anagnostopoulos F, Lempesis E, Valindra A. Doctors' emotion regulation and patient satisfaction: A social-functional perspective. Health Communication. 2014;**29**(2):205-214. DOI: 10.1080/ 10410236.2012.738150

[21] Cohen-Cole SA. The "difficult" medical patient. In Walker HK, Hall, WD, & Hurst, JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed. Butterworths. Boston. 1990. pp. 1045-1049

[22] Coran JJ, Koropeckyi-Cox T, Arnold CL. Are physicians and patients in agreement? Exploring Dyadic Concordance. Health Education & Behavior. 2013;**40**(5):603-611. DOI: 10.1177/1090198112473102

[23] Hoffman KM, Trawaltera S, Axta JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. PNAS. 2016;**113**(16): 4296-4301

[24] Street RL, Gordon H, Haidet P. Physicians' communication and perceptions of patients: Is it how they look, how they talk, or is it just the doctor? Social Science & Medicine. 2007;**65**:586-598

[25] Evers S, Hsu C, Sherman KJ, et al. Patient perspectives on communication with primary care physicians about chronic low back pain. The Permanente Journal. 2017;**21**:16-177. DOI: 10.7812/ TPP/16-177

[26] Quill TE. Recognizing and adjusting to barriers in doctor-patient communication. Annals of Internal Medicine. 1989;**111**:51-57

[27] Reisch T, Ebner-Priemer UW, Tschacher W, Bohus M, Linehan MM. Sequences of emotions in patients with borderline personality disorder. Acta Psychiatrica Scandinavica. 2008;**118**: 42-48. DOI: 10.1111/j.1600-0447.2008. 01222.x

[28] Nisselle P. Difficult doctor-patient relationships. Australian Family Physician. 2000;**29**(1):47-49

[29] Ward RK. Assessment and management of personality disorders. American Family Physician. 2004;**70**(8):1505-1512

[30] Linklater D, Macdougall S. Boundary issues: What do they mean for family physicians? Canadian Family Physician. 1993;**39**:2569-2573

[31] Morse DS, McDaniel SH, Candib LM, Beach MC. "Enough about Me, Let's Get Back to You": Physician self-disclosure during primary care encounters. Annals of Internal Medicine. 2008;**149**(11):835-837

[32] Raja S, Hasnain M, Hoersch M, Gove-Yin S, Rajagopalan C. Trauma informed care in medicine current knowledge and future research

*Perceptive Chapter: "Are We Listening?" - Improving Communication Strategies and… DOI: http://dx.doi.org/10.5772/intechopen.105151*

directions. Family & Community Health. 2015;**38**(3):216-226

[33] Janisse T, Tallman K. Can all doctors be like this? Seven stories of communication transformation told by physicians rated highest by patients. The Permanente Journal. 2017;**21**:16-097. DOI: 10.7812/TPP/16-097

[34] Calkins DR, Davis RB, Reiley P, Phillips RS, Pineo KLC, Delbanco TL, et al. Patient-physician communication at hospital discharge and patients' understanding of the postdischarge treatment plan. Archives of Internal Medicine. 1997;**157**:1026-1030

[35] Ventres W. ABCDE in clinic encounters: Presentations of self in doctor-patient communication. Annals of Family Medicine. 2015;**13**:276-278. DOI: 10.1370/afm.1755

[36] Claramita M, Arininta N, Fathonah Y, Kartika S, Prabandari YS, Pramantara IDP. A partnership-oriented and culturally-sensitive communication style of doctors can impact the health outcomes of patients with chronic illnesses in Indonesia. Patient Education and Counseling. 2020;**103**(2):292-300

[37] Claramita M, Susilo AP, Kharismayekti M, van Dalen J, van der Vleuten C. Introducing a partnership doctor-patient communication guide for teachers in the culturally hierarchical context of Indonesia. Education for Health. 2013;**26**(3):147-155

[38] Frankel RM, Stein T. Getting the most out of the clinical encounter: The Four Habits Model. The Permanente Journal. 1999;**3**(3):79-88

[39] Ludeby T, Gulbrandsen P, Finset A. The expanded Four Habits Model—A teachable consultation model for encounters with patients in emotional distress. Patient Education and Counseling. 2015;**98**(5):598-603

[40] Stensrud TL, Gulbrandsen P, Mjaaland TA, Skretting S, Finset A. Improving communication in general practice when mental health issues appear: Piloting a set of six evidencebased skills. Patient Education and Counseling. 2014;**95**(1):69-75

[41] Haidet P. Nurturing patientcenteredness in a hectic world. The Maryland Family Doctor. 2008;**44**(4): 15-16

[42] Hardee JT, Kasper IK. A clinical communication strategy to enhance effectiveness and CAHPS scores: The ALERT Model. The Permanente Journal. 2008;**12**(3):70-74

[43] Klitzman R. "Patient-time," "doctortime," and "institution-time": Perceptions and definitions of time among doctors who become patients. Patient Education and Counseling. 2007;**66**(2):147-155. DOI: 10.1016/j. pec.2006.10.005

## Section 4
