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Interdisciplinary Team Communication Among Forensic Nurses and Rape Victim Advocates Debra Patterson PhD

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School of Social Work, Wayne State University, Detroit, Michigan, USA Published online: 09 Apr 2014.

To cite this article: Debra Patterson PhD (2014) Interdisciplinary Team Communication Among Forensic Nurses and Rape Victim Advocates, Social Work in Health Care, 53:4, 382-397, DOI: 10.1080/00981389.2014.884040 To link to this article: http://dx.doi.org/10.1080/00981389.2014.884040

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Social Work in Health Care, 53:382–397, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0098-1389 print/1541-034X online DOI: 10.1080/00981389.2014.884040

Interdisciplinary Team Communication Among Forensic Nurses and Rape Victim Advocates DEBRA PATTERSON, PhD Downloaded by [University of Illinois Chicago] at 02:56 11 November 2014

School of Social Work, Wayne State University, Detroit, Michigan, USA

Victim advocates and forensic nurses provide integrated care to address the complex legal, medical, and mental health needs of rape survivors. Research suggests that conflict exists between nurses and advocates, but it remains unknown how their communication patterns contribute to or resolve these conflicts. Utilizing a qualitative case study approach, the current study interviewed 24 nurses and advocates from a Midwest organization to better understand team communication patterns when addressing conflicts. The findings suggest that most nurses communicate concerns directly while advocates avoid direct communication. Factors that influenced direct and indirect communication and their implications for practice will be discussed. KEYWORDS communication, interdisciplinary teams, victim advocates, forensic nurses

INTRODUCTION A critical element of successful interdisciplinary collaborations is open communication, which the literature has characterized as sharing opinions and information honestly and freely among professionals (Cole & Logan, 2008; Robinson, Gorman, Slimmer, & Yudolwsky, 2010). Open communication between disciplines has been linked to effective coordination of services, improved quality of care, and reducing stereotypes of other disciplines (Drabble, 2010; King & Ross, 2004; Youngswerth & Twaddle, 2011). Alternatively, absence of communication among disciplines is a strong

Received July 3, 2013; accepted January 13, 2014. Address correspondence to Debra Patterson, School of Social Work, Wayne State University, 4756 Cass Avenue, Detroit, MI 48326. E-mail: [email protected] 382

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contributing factor to team conflicts and tension. One example of this tension has been found in research examining the interdisciplinary relationship between forensic nurses and victim advocates who provide integrated services to sexual assault survivors within a sexual assault nurse examiner (SANE) program (Cole & Logan, 2008; Payne, 2007). SANE programs were developed to improve services for sexual assault survivors by having specially trained forensic nurses provide acute health care and medical forensic exams, while advocates attend to the survivors’ emotional needs (Campbell, Patterson, & Lichty, 2005). Research has suggested that conflicts occur sometimes between nurses and advocates and may result, in part, from ineffective communication (Cole & Logan, 2008; Cole, 2011). However, conflicts resulting from ineffective communication between forensic nurses and victim advocates may be an inevitable component of their collaboration. For example, nurses and advocates have limited time to communicate because most forensic nurses hold contractual positions, while the majority of advocates have volunteer status (Cole & Logan, 2008). Thus, communication between the nurses and advocates may only occur during service delivery, which may be an inappropriate time to address any conflicts that may arise. Further, they only provide services during on-call shifts, so the frequency that individual nurses and advocates work together can vary greatly, which may limit their ability to build relationships conducive to open communication (King & Ross, 2004; Kutash et al., 2013). The traditional nature of the advocacy role also may pose challenges to effective communication. Prior to the inception of SANE programs, advocates had the role of protecting survivors from hurtful interactions with health care by challenging stereotypes and intervening when witnessing victim blaming and other insensitive responses (Martin, 2005). This has been an important component of advocacy because studies suggest that many survivors encounter hurtful responses from health care, particularly by untrained professionals (Fehler-Cabral, 2011–12). However, forensic nurses employed by SANE programs receive training on sensitive care of survivors, so the advocacy component may not be needed or perceived as needed by nurses (Campbell et al., 2005). Furthermore, the nurses and advocates have more of an ongoing professional relationship since the integration of services, meaning that advocates confronting nurses about insensitive reactions could negatively impact that relationship (Cole, 2011). It is also possible that a collegial relationship may influence the advocates’ approach to confronting nurses. Open communication appears to be a critical ingredient in conflict management and team effectiveness, while the incapacity to address conflict can weaken team effectiveness (Callaly, von Treuer, van Hamond, & Windle, 2011; Kutash et al., 2013). Research has shown that ineffective communication can impact the safety and quality of care of patients (Robinson, Gorman, Slimmer, & Yudlowsky, 2010; Youngwerth & Twaddle,

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2011). In addition, unresolved conflicts can undermine collaborative initiatives and team growth (Cole & Logan, 2010). The current study examined one interdisciplinary team’s communication process to understand the elements that foster and hinder open communication among nurses and advocates. The current study utilized a qualitative case study framework, which can provide an in-depth understanding of an issue experienced by professionals within an organization (Creswell, 2012; Stake, 2005).

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METHODS Background and Participants This study was a result of a longstanding research partnership with a large Midwestern rape crisis center that provides advocacy and SANE services. The organization began in the late 1970s as a volunteer-run grassroots organization. Over time, the organization grew and began hiring degreed professionals to staff most of the organization, but the advocacy program continues to be staffed by volunteers. The advocacy program is administered by an employee who reports to a social service director, who in turn reports to the organization’s associate director. The focal SANE program began in the late 1990s and is staffed by forensic nurses (RNs) who hold contractual employment with the organization. The SANE program is administered by a director who reports to the associate director. Although the nurses and advocates provide services as a team, they have separate trainings and meetings. After the inception of the SANE program, the supervisors provided frequent opportunities for the nurses and advocates to socialize, but these ceased with changes in leadership. Sample eligibility includes advocates and nurses who provide crisis services to rape survivors. To recruit participants, the PI attended staff meetings to introduce the study. Participants were asked to complete a contact form if they were interested in participating. All of the 11 nurses and 13 advocates completed a form and were contacted to schedule an interview. One nurse did not participate due to scheduling conflicts resulting in a final sample of 10 nurses and 13 advocates (96% response rate). This is a reasonable sample size for a qualitative study examining a phenomenon in-depth (Creswell, 2012). The average years of experience were five years, with a range of three months to 15 years. The number of survivors served ranged from three to 900, with an average of 213 cases.

Procedures In-depth, one-time interviews were conducted in a private location convenient for the participants. Field notes identified emerging themes and topics that needed more exploration in subsequent interviews (Creswell, 2012).

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The interviews ranged from 31 to 90 minutes in length, with an average of 54 minutes. The interviews were tape recorded and transcribed by research assistants, and checked for errors. The author has observed the advocacy and nursing trainings and read organizational documents (organizational chart, policies), which informed the study. The procedures used in this study were approved by the Wayne State University Institutional Review Board.

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Measures The semi-structured interview protocol was informed by the literature on the team dynamics of forensic nurses and advocates. In addition, we consulted advocates and forensic nurses locally and nationally, and revised the interview protocol following those consultations. The interview consisted of three topics: (1) the unique contributions of advocates within a SANE program; (2) the nature of the team functioning between forensic nurses and advocates including communication; and (3) how to improve functioning. The current study examined the second and third areas with a primary focus on communication between advocates and nurses and the elements that foster or hinder open communication. Specific interview probes included (a) in what ways do the advocates and nurses work well and not work well as a team; (b) how do you communicate your concerns; and (c) what would help improve communication?

Data Analyses Consistent with Creswell’s (2012) method of case analysis, data analysis began during data collection by writing a detailed description of the advocate–nurse team. Next, two analysts independently read the transcripts, wrote memos, and formed initial codes, which led to the identification of themes. The analysts compared themes, discussed the meaning of the thematic codes, and revised the coding framework until there was consensus. Patton (2002) asserts that the “ultimate test” (p. 561) of credibility rests with the primary users of the findings, so the findings were shared with five supervisors/directors (three of whom participated in the study) from the organization. They noted that the findings reflected the current communication process between the nurses and advocates, as well as the elements that fostered and hindered open communication.

RESULTS Overall, the participants indicated that conflicts between the nurses and advocates were infrequent but resulted in lingering tension. When conflicts did occur, they tended to occur when the nurses and advocates disapproved of each other’s approach with patients (e.g., making an inappropriate

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comment to the patient), and misunderstood each other’s roles (e.g., nurses requesting the advocates to perform clerical tasks). While conflicts among interdisciplinary teams are common (Cole & Logan, 2008), the process of communicating those conflicts can play an important role in reaching resolutions or creating programmatic changes. The following results identify two primary approaches taken by the advocates and nurses to resolve conflicts through communication, as well as the factors that influence those approaches.

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Communicating Conflicts The advocates and nurses were asked how they communicate their concerns. All of the participants noted that addressing their concerns in front of survivors would be inappropriate because it might create an uncomfortable environment for the survivor. However, communication styles differed between advocates and nurses outside the presence of the survivor. When advocates had a concern about a nurse, most of the advocates communicated their concerns primarily to their supervisor rather than the nurse directly (termed indirect communication). Once the advocacy supervisor is notified of a problem, the path of communication tends to involve many supervisors before the individual nurse is notified of the concern. One advocate compared this path of communication to a tent:

I can’t think of a time that I would ever say anything to the nurse directly. I would take their inappropriateness to the [advocacy coordinator], who would then take their inappropriateness through her boss who would then bring it back down through [nurse director], or [nurse co-director], or whoever they decide is in charge and then down to that nurse. It’s this weird tent-shaped mode of communication. (Advocate 102)

Alternatively, most of the nurses preferred discussing their concerns directly with the advocates (termed direct communication): “You take them aside, apart [from the patient], separately, and then, yes, you clarify what you saw that was inappropriate or they should not be doing, or whatever” (Nurse 204).

What Influences Communication Style The participants indicated four primary influences for their communication styles: preventing tension with their colleagues; the likelihood of a successful outcome; the severity of the situation; and the perception of whether their role includes addressing concerns directly.

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PREVENTING TENSION Preventing tension between the nurses and advocates was the primary factor that influenced the participants’ communication style. However, their perceptions of how communication can prevent tension differed. For instance, all of the advocates who reported their concerns to their supervisor did so to avoid tension with the nurses. They explained that addressing their concerns with the nurses directly would cause tension in the relationship: “I don’t want to destroy what little bond I have with a nurse that I don’t like so much by saying to them, wow you are, this is not great. Because then, you really do need to work with them, you can’t avoid them . . . ” (Advocate 102). The nurses, on the other hand, utilized direct communication to prevent tension. They believed that communicating through a chain of command would provide only one perspective of the situation, which may misconstrue the problem. They stated that indirect communication would create festering tension and eventually create divisions between the nurses and advocates. Thus, these nurses preferred communicating their concerns with the advocates directly to prevent tension from occurring: “I think pretty much in any situation where you have a disagreement with someone it’s always best to try to work it out amongst the two people first. It can get way blown out of proportion if you go above and beyond [to a supervisor]” (Nurse 206). There’s three sides to a story. So, you don’t know what my perspective is. How fair is that to the person that really had some good reasons that you don’t have the whole story and you don’t know a hundred percent of what went on, and, it’s unfair, and you’re not getting an accurate presentation of everything that goes on. . . . (Nurse 209)

Unfortunately, some nurses believed that the advocates’ indirect communication has contributed to growing tension between the nurses and advocates: I think the division is now. . . . Kind of like, losing respect [for the advocates] too; it’s just the advocates being advocates again. Like, being sensitive, not giving them respect either because it’s just the advocates chirping again, and being hyper-sensitive. Instead of, like, oh really that happened, okay let’s figure that out, that wasn’t good. It’s like, alright what’s their complaint now. . . . Your executive directors and everyone shouldn’t know that someone didn’t cross a T on a paper. It should be able to be handled within the program within each other. Instead of having to get everyone involved. . . . And does the nurse trust that the advocate is on their side now? No. Instead of a support person, it’s now we’re not united as a team. (Nurse 203)

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It appears that nurses may perceive indirect communication as complaining rather than the advocates attempting to create professional or programmatic improvements. As a result, the advocates’ feedback may lose its validity and thus, be less likely to be taken seriously or applied.

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PERCEIVED LIKELIHOOD

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SUCCESSFUL OUTCOME

Many of the advocates and nurses also choose their communication styles based on the likelihood of individual or programmatic change occurring. For example, many advocates believed that the nurses would not take them seriously if they approached them directly, but believed that change was more likely to occur if they reported the problems to their supervisor. I don’t think it’s really gonna make any difference [to talk to the nurse], and if maybe it’s just going to create awkwardness between us, instead of helping. I think instead of saying one on one to her, like “I would have probably done that differently,” I’m going to instead say it to [advocacy coordinator] to try and make more of a macro change. (Advocate 103)

Nurses, on the other hand, believed that reporting to a supervisor is ineffective because going through the “chain of command” delays feedback, making it more challenging to remember the original situation. They also believed that addressing concerns directly would allow their colleagues to explain why they approached the survivor in a particular manner and would lead to a discussion of the best approaches to working with survivors. If it happens at that time, she needs to tell me then, not a month from now, or six weeks from now, or after it’s gone up the chain of command and back down again because by then I’ve forgotten what happened, or have to rethink about what I did, and it’s too late then. It’s like, that’s why that communication needs to be there. You need to be able to have that communication because otherwise you don’t work effectively as a team. . . . I need to know that I’ve done something, or that I’m doing something that. . . . Stepping over a bound or, um, the advocate or the client thought was inappropriate, I need to know that, so that I can step back or take a look at it, and change something. (Nurse 204)

Furthermore, many nurses believed that reporting a problem to a supervisor has not been effective in promoting change as only one nurse indicated being approached by her supervisor about a specific complaint. This might suggest that the advocates’ reported concerns are not reaching the nurses. The advocates, meanwhile, noted that their reported concerns have continued to persist. However, they attributed this lack of change to nurses’ resistance rather than a breakdown in communication: “We’ve taken

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[a concern] to [Advocate Coordinator] and she’s taken to blah, blah, blah. So they’ve [nurses] heard it but they continue to do certain things. You know, over and over, so that’s not anything new it’s just irritating. . . . ” (Advocate 106) If the nurses are indeed not being informed of problems when the advocates believe notification has occurred, it could contribute to overall tension as the advocates become frustrated with what they perceive to be a lack of responsiveness to their concerns.

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SEVERITY

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The participants who used indirect communication were asked if there was any situation that would influence them to communicate directly. These participants noted that they would address their colleague directly if they witnessed something that was clearly inappropriate or severe enough to require intervening immediately. Where with them [nurses] giving a remark to the survivor, or something like that, that’s just like outright wrong. There’s no, like, if, ands, or buts, like, about it, that’s just wrong and inappropriate. It’s clearly defined that you crossed that line. So, I wouldn’t have a problem saying anything. (Advocate 110)

In addition, these participants noted that they would be more likely to address their colleague directly if they believed the problem was a repeated rather than an isolated incident. However, the participants noted that assessing the frequency of a problem was challenging because there were limited opportunities for the nurses and advocates to know one another. I don’t work with these nurses on a regular basis, I don’t know them as well, so there would be that awkwardness of starting a conflict with someone which, maybe if I talked to [Advocate Coordinator] she can maybe get some insight about it and maybe my perception was off, she would know the nurse to know if this was a personality conflict, if I was sensitive in this situation, so that I would have more comfort with that. I’m not here on a daily basis; I don’t know these people. (Advocate 107)

ADDRESSING CONCERNS

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Some of the advocates who used indirect communication believed that approaching the nurses about their concerns was the role of the supervisor rather than the advocates. Although a formal policy does not exist about communicating problems, these advocates believed that reporting problems to a supervisor rather than the nurse was the norm. Alternatively, the

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advocates who utilized direct communication believed that addressing issues immediately was an important component of the advocacy role because it helps improve the treatment of survivors: “I stick up for those people who don’t have a voice, or a say in the matter . . . if a nurse says anything inappropriate, I’d take her outside and ask her how would she feel if somebody said that to her daughter” (Advocate 108). Advocating for better treatment of survivors was the most salient factor that influenced these advocates to address their concerns directly. Similarly, the nurses want the advocates to address their concerns directly to prevent poor patient care. In fact, the nurses expected to be informed if the advocates witness them interacting with the survivor in a way that might be disempowering or hurtful: “So, maybe it’s a day where I’m off, and maybe I did do something that I didn’t even realize I was doing, but upset the advocate or, by the same token, may have upset the client. Well, how am I going to know that I did that, unless I’ve gotten this communication back?” (Nurse 204). As indicated above, these participants believed that the advocates’ direct communication served as an important mechanism to improve the nurses’ approach with survivors. Additionally, the nurses believed that addressing their concerns directly with advocates improved service delivery. In the example below, the nurse discusses how she handled a situation where the advocate contradicted the nurse in front of a patient about the nurse’s plan of care: There are advocates out there that sometimes I just want to say, okay zip it, quiet, you’re going too far, or you’ve overstepped the bounds. And, I’ve only had that happen a couple of times, and I, um, afterwards—I would never do it in the room [with the patient]—say think about this, while this was going on and I was asking these questions, and you interrupted, and this is what you said in direct contradiction, I said, is that really the best thing for the patient. I said, what’s going on, what do you think, what did you see that I didn’t see, and this is what I saw, and could we have handled it differently, could we have used other words. And that one person I didn’t get any response from because I don’t think she agreed with what I said, but I never had the problem again. (Nurse 209)

Although this direct communication did not lead to a more in-depth discussion of the problem, the nurse deemed this as successful because the advocate no longer went outside the scope of her expertise.

Participants’ Recommendation: Becoming Better Acquainted The participants were asked what could improve communication between the advocates and nurses. All of the participants mentioned that they do not have opportunities to meet formally and informally (e.g., holiday party)

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outside of a call. Many participants noted that they often meet one another for the first time during a call. The participants believed that developing a trusting relationship would help with communication because they would feel more comfortable with each other, thus leading them to function better as a team. In addition, the advocates who used indirect communication to avoid tension believed that they would be more likely to communicate their concerns directly if they had more solid relationships with the nurses. In particular, these advocates believed that building relationships with the nurses would make them feel more comfortable providing direct feedback and would result in the nurses being more receptive to their feedback. The participants who use direct communication also believed that stronger relationships make raising concerns with each other easier, as well as bring about a sense of team unity.

DISCUSSION Overall, the nurses and advocates differed in their approach to resolving conflicts through communication. While most nurses communicated their concerns directly to advocates, few advocates addressed their concerns to the nurses directly. Instead, the advocates reported the concerns to their supervisor, which led to multiple discussions with other supervisors over the span of months before the nurse was informed of the concern, if they were informed at all. This made it difficult for the nurse to remember the situation or learn from the situation when applicable. For example, the advocates occasionally witnessed nurses responding to survivors in a potentially hurtful manner. When these concerns were not communicated, there was missed opportunity for the nurses to understand how their response could improve. Interestingly, the nurses wanted this type of feedback from the advocates. Further, this study identified multiple factors that promoted or inhibited the participants from communicating their concerns directly to each other. Preventing tension was the most salient factor that influenced the participants’ approach to resolving conflict, but the nurses and advocates differed in what type of communication they believed averts tension. The nurses tended to believe in addressing their concerns directly, while advocates routed their concerns to supervisors to avoid tension. Although the advocates wanted a harmonious relationship, the findings parallel prior research that suggests that indirect communication contributes to tension because it can cause misunderstandings (King & Ross, 2004; O’Connor & Fisher, 2011). Over time, these misunderstandings can impair collegiality as unresolved conflicts can negatively shape each discipline’s perception of the other and may even lead each discipline to view the other as the enemy (Callaly et al., 2011; Cho & Hung, 2011; Tjosvold, 2008).

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Avoiding direct communication is a common strategy utilized by many disciplines in order to maintain harmony (Tjosvold, 2008), but why would the advocates avoid direct communication and not the nurses? One primary reason may be their perception of whether direct communication will produce change. The nurses’ preference for direct communication may be influenced by their primary employment in emergency departments, where immediate corrective feedback is the norm as it is critical during medical emergencies. The nurses indicated that addressing concerns immediately to the advocates resolved the problem. The advocates, on the other hand, believed that change would be more likely to occur if their supervisor handled the concerns. While communication patterns between nurses and advocates have not been studied in-depth, Kharicha and colleagues (2005) found a similar communication pattern of social workers routing their concerns through supervisors rather than directly with health care professionals. Research suggests that avoiding direct communication can indicate perceived or actual lack of power within an organization (Syna, Emek, College, & Yagil, 2005; Wang, Fink, Cai, 2012). The advocates are volunteers who are provided with extensive training but are not required to have a professional degree, even though a few do. Cole and Logan (2008) have suggested that inequality exists between advocates and nurses, and that the advocates’ volunteer status may contribute to that inequality. However, only a couple of advocates wondered if the nurses do not value their feedback because of their volunteer status, while none of the nurses raised the advocates’ volunteer status as a concern. However, research that has examined communication patterns between physicians and allied health professionals found that power can play a role in communication (Lingard et al., 2012; O’Connor, & Fisher, 2011). Lingard and colleagues posited that physicians in particular engaged in more assertive communication because they viewed themselves as the leaders of the multidisciplinary team, and had more legal and professional liability. In the current study, the nurses may view themselves as the leaders of the program because they do have professional liability and are employees, which may lead them to being more vocal with their concerns. Further, the advocates did share that they felt unequal in their partnership with the nurses because they believed that the nurses perceived them as less important. This may result in the advocates feeling they are unable to affect meaningful change and believing that reporting to their supervisor is the only way to obtain the desired result. Further research is needed to systemically examine how the advocates’ volunteer status affects their approach to communicating concerns, along with additional investigation to understand the essential team dynamics needed to empower all members to voice their concerns openly. Although the advocates routed their concerns to a supervisor because they worry that their feedback will not be taken seriously, this indirect approach risks that the original concern will be taken out of context, making what may be a minor issue into a more disconcerting problem. Some of

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the nurses have reported that indirect communication exacerbated the original concern, leading the nurses to view the advocates as overreacting and complaining. Thus, the advocates’ feedback had lost its validity. The nurses and advocates also noted that they lack familiarity with each other, which makes open communication more challenging. On-call and shift work is common in health care settings, but it can inhibit each discipline from knowing each other well unless they have worked together frequently (Kutash et al., 2013). However, this lack of familiarity seems to influence advocates’ communication more than the nurses’. The advocates noted that this unfamiliarity makes direct communication more risky because they could not predict how the nurses would respond or if it would produce tension rather than change. The nurses, on the other hand, have experience working in emergency departments where they may have become accustomed to providing feedback to those with whom they are less familiar. Another contributing factor that influenced communication was whether the participants considered addressing concerns as part of their role. The nurses viewed communicating concerns as part of their role, but the advocates were divided. Most advocates believed addressing concerns was their supervisor’s role. This idea may be due to the fact advocates provide crisis intervention with survivors alone in a private room and hold the responsibility of protecting the survivors’ confidentiality. They are limited in the information that they can share with the nurses (Cole, 2011), which necessitates debriefing their calls only with their supervisor. Thus, it may be possible that some of the advocates view the debriefing as the appropriate forum to address their concerns about the nurses. However, a few of the more experienced advocates believed addressing concerns immediately was an important part of the advocacy role in preventing harm to survivors. Furthermore, these experienced advocates had less concern that this communication would produce tension or not be received well; their primary concern was to improve the response to survivors. One primary reason for this difference may rest with the historical roots of advocacy services, nationally and locally. Prior to SANE programs, survivors were examined in emergency departments, often by medical personnel who were not trained in providing sensitive empowering care (Campbell et al., 2005). That meant part of the advocates’ role involved confronting medical professionals who were approaching survivors in a hurtful manner (Martin, 2005). However, forensic nurses receive training on sensitive patient care, meaning there is less of a need for advocates to employ these confrontational approaches to protect survivors. Locally and nationally, advocates’ strategies to effect change became less confrontational when they began collaborating with mainstream organizations, such as SANE programs (Martin, 2005). The inexperienced advocates began providing services after this shift to the less-confrontational approach. Additionally, communicating concerns to health care no longer appears in their training curriculum. The experienced advocates also have

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known some of the nurses for a longer period of time, which may make it easier for them to predict how a nurse will respond to their feedback. This highlights the importance of training and relationship development on communication. Finally, administrative factors may play a role in the advocate–nurse team communication. As noted earlier, most advocates’ concerns are routed through a chain of command, which delays the nurses being informed of the concerns. The reason for this lengthy process was unclear, and no one knew why the nurse and advocacy supervisors do not address the concern themselves. One possibility may be that the nurse and advocacy supervisors work in different office buildings, which research suggests may hinder communication and relationship building (Kutash et al., 2013). Additionally, the nurse and advocacy supervisors do not have scheduled meetings to address programmatic concerns. The advocacy supervisor, instead, discusses the concerns with her own supervisor, whose office is in the same building. This communication pattern may have started out of convenience; however, it parallels the advocates’ communication process. This demonstrates the influence that administrators’ communication style can have on their teams. Because the advocacy and nursing supervisor serve as a model for team communication, the nurses–advocate communication may not change until the supervisors resolve team issues together. Further research is needed to understand the dynamics between interdisciplinary team leaders, and how these dynamics inhibit or facilitate team communication. A few methodological limitations of this study warrant consideration. The qualitative nature of this project limits the conclusions that can be drawn about causality and the extent to which these findings can be generalized to other advocate–nurse teams. The retrospective nature of this study depends on the participants’ memories, as well as self-disclosure that can be influenced by social desirability. Therefore, factors influencing intra-team communication may have been omitted. For example, leadership has the ultimate responsibility for the effectiveness of team functioning (Sheehan, Robertson, & Ormond, 2007), but the supervisors were rarely mentioned as a factor influencing communication. The couple of participants who mentioned their immediate supervisors indicated that the leaders tend to avoid communicating conflict with each other. Given the influential role of leaders, the supervisors may have played a larger role in the nurses’ and advocates’ communication. Thus, understanding how leaders influence their teams’ approach to communicating conflict merits additional research. Finally, the sample included advocates and nurses from a program administered by a rape crisis center. Thus, these findings may not be generalizable to other advocate–nurse teams, particularly those teams that are overseen by two separate organizations, such as when nurses are employed by hospitals and the advocates are supervised by rape crisis centers. In these types of teams, advocates may feel like outsiders when the

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SANE program is administered by a hospital, so other factors may influence them to communicate their concerns directly or indirectly, if at all. Future research should explore whether programmatic administration and structure influences communication between nurses and advocates. Despite these limitations, this study has several implications for practice. This study highlights an absence of interdisciplinary team dynamics, such as sharing information or professional opinions, and spending formal and informal time together (Bronstein, 2003; Sheehan et al., 2007). However, a shift to a true interdisciplinary approach might enhance patient services. For example, advocates and nurses often provide services without direct supervision, so providing feedback with each is necessary to improve the quality of patient services. In addition, providing services to sexual assault survivors can be emotionally taxing and result in secondary trauma (Collins & Long, 2003). Strong collegial relationships have been shown to alleviate symptoms of secondary trauma (Geller, Madsen, & Ohrenstein, 2004). The advocates and nurses can emotionally support each other and discuss the emotionality of cases immediately following service provision. However, this type of interdisciplinary approach requires trust and cohesion between the disciplines (Bronstein, 2003; Cho & Hung, 2011; Lidskog, Löfmark, & Ahlström, 2007), which was not evident in the interviews and appears to be a struggle among many nurse–advocate teams across the country (Cole & Logan, 2008). The nurses and advocates in the focal program have not initiated formal meetings as a strategy to resolve their conflicts. While the absence of interdisciplinary meetings is common among many disciplines (Abramson & Bronstein, 2006; Syna et al.,2005), meetings provide the opportunity to promote team cohesion (Callaly et al., 2011; Cho & Hung, 2011). In particular, meetings can foster team unity by addressing conflict openly, assessing their interprofessional communication, and providing feedback aimed to strengthen the effectiveness of their relationship (Bronstein, 2003; King & Ross, 2004). Furthermore, evaluating intrateam communication competencies may help team members to assess their team functioning and address concerns as indicated (Thompson, 2009). In conclusion, strengthening relationships requires courage for team members to communicate openly (Thompson, 2009), which most advocates have avoided. Reframing conflict may help advocates shift to open communication. Because conflict is an inevitable consequence of collaboration, ongoing conflict management should be the goal rather than promoting harmony (Tjosvold, 2008). By providing feedback openly during calls and meetings, tension and frustration might be reduced as the team moves toward problem solving (Chen & Tjosvold, 2007; Tjosvold, 2008). As such, conflict needs to be reframed as an important part of improving services to sexual assault survivors.

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Interdisciplinary team communication among forensic nurses and rape victim advocates.

Victim advocates and forensic nurses provide integrated care to address the complex legal, medical, and mental health needs of rape survivors. Researc...
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