Nursing_teamwork,_staff_characteristics,_work.5
Nursing teamwork,staff characteristics,work schedules,and staffing
Beatrice J.Kalisch Hyunhwa Lee
Purpose:This study aimed to explore whether and how staff characteristics,staffing,and scheduling variables are associated with the level of teamwork in nursing staff on acute care hospital patient units.
Design:This was a cross-sectional study with a sample of 1,758nursing staff members from two different
hospitals on 38patient care units who completed the Nursing Teamwork Survey in 2008.This study focused on nursing teams who are stationed on a particular patient care unit (as opposed to visitors to the units).The return rate was 56.9%.The sample was made up of 77.4%nurses (registered nurses and licensed practical nurses),11.9%assistive personnel,and 7.9%unit secretaries.
Findings:Teamwork varied by unit and service type,with the highest scores occurring in pediatrics and maternity and the lowest scores on the medical–surgical and emergency units.Staff with less than 6months of experience,those working 8-or 10-hour shifts (as opposed to 12hours or a combination of 8and 12hours),part-time staff (as opposed to full time),and those working on night shift had higher teamwork scores.The higher teamwork scores were also associated with no or little overtime.The higher perception of the adequacy of staffing and the fewer patients cared for on a previous shift,the higher the teamwork scores.
Conclusions:There is a relationship between selected staff characteristics,aspects of work schedules,staffing,and teamwork.Nursing staff want to work where teamwork is high,and perceptions of good staffing lead to higher teamwork.Higher teamwork scores correlated with those who worked less overtime.
T
he patient safety movement has brought a great deal of attention to teamwork in health care.High-reliability organizations are those whose
complex work might produce errors or accidents,yet they have been successful in avoiding most accidents through a focus on error prevention (e.g.,aviation and nuclear power).These organizations are highly complex and contain many risk factors (Kalisch &Aebersold,
2006).Health care,and within it nursing,certainly meet the criteria for this type of organization.
The connection between safety and teamwork in health care has been established.The now-classic In-stitute of Medicine (IOM)study To Err is Human first revealed that an estimated 44,000to 98,000errors are made per year (IOM,2000).Because that report was published,there has been a significant amount of research and process improvement efforts to make health care safer.The IOM (2000)report made recommendations to increase safety such as systems changes,error reporting,standards development,and enhanced teamwork.The Agency of Healthcare Research and Quality (2008)is one of the organizations that have taken responsibility for implementing the recommendations of the report.The definition of a team is a group of individuals with a common purpose who need one another to achieve their goals.This report focuses on inpatient unit teams or those individuals who work together on a particular unit to care for a group of patients (medical,surgical,intensive care,etc.).This is usually made up primarily of
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Health Care Manage Rev ,2009,34(4),323-333
Copyright A 2009Wolters Kluwer Health |Lippincott Williams &Wilkins
Beatrice J.Kalisch,PhD,RN,FAAN,is Chair,Nursing Business and Health Systems,and Titus Distinguished Professor,University of Michigan,School of Nursing,Ann Arbor.E-mail:bkalisch@https://www.wendangku.net/doc/5a6201568.html,.Hyunhwa Lee,RN,MSN,PhDc,is Research Associate,Uni-versity of Michigan,School of Nursing,Ann Arbor.
This study was approved by the University of Michigan’s institutional review board.
Key words:acute care,nurse,nursing,satisfaction,staffing,teamwork
registered nurses(RNs),assistive personnel(NAs),and unit secretaries(USs).Using the definition provided earlier,nursing team members perform interdependent tasks(e.g.,one nurse cares for patients on day shift and another on night shift,the RN cannot provide care if the US does not take the orders off,it usually takes more than one team member to ambulate a patient,etc.)while functioning in specific roles(RN,NA,and US)and sharing the common purpose of providing safe quality care.Unfortunately,many nursing teams are a collection of individuals who do not engage in the teamwork behaviors of monitoring one another’s performance, backing each other up,engaging in closed-loop commu-nication and effective conflict resolution,or sharing the same ideas and understandings of what needs to be done for the patient and family(shared mental models;Clancy &Tornberg,2007;Kalisch,Weaver,&Salas,in press). Further,there is often a problem with lack of ade-quate leadership.
Teams who are functioning well make fewer errors than do individuals working alone(Baker,Day,&Salas,2006; Smith-Jentsch,Salas,&Baker,1996;Volpe,Cannon-Bowers,Salas,&Spector,1996).For example,a study of two groups of pilots,one exhausted but had worked to-gether for a time and another group who had not worked as team but were fully rested,found that the tired team made fewer errors than did the rested team(Carter&West, 1999).Leonard,Graham,and Bonacum(2004)described an analysis of2,455sentinel events reported to the Joint Commission,of which75%of the incidences resulted in death(Leonard et al.,2004).Over70%of the incidents revealed the primary root cause to be communication failure,with evidence that the team members had very different perceptions of what was supposed to happen.
Conceptual Framework
Salas,Sims,and Burke(2005)have conducted a large amount of research identifying eight key elements of teamwork:(a)team leadership(i.e.,structure,direction, and support provided by both the formal leader and the other members of the team),(b)collective orientation (i.e.,cohesiveness and individuals see the team’s suc-cess as taking precedence over individual needs and per-formance),(c)mutual performance monitoring(i.e., observation and awareness of team members and un-derstanding team roles),(d)backup(i.e.,helping one another with their tasks and responsibilities),(e)adapt-ability(i.e.,ability to adjust strategies and resource allocation based on information gathered from the envi-ronment),(f)shared mental models(i.e.,mutual concep-tualizations of the task,roles,strengths and weaknesses, processes,and strategy necessary to attain interdepen-dent goal),(g)closed-loop communication(i.e.,active information exchange in which receiver verifies receipt and the sender verifies that the intended message was received),and(h)mutual trust(i.e.,shared perception that members will perform actions necessary to reach interdependent goals and act in the interest of the team).
Research Questions
This study focuses on nursing teamwork in acute care hospitals and among the group of individuals who are permanent staff on the patient care unit.Although teamwork between nursing unit staff and others who visit the unit,such as physicians,physical therapy, dietary,and so forth,is equally important,this study targets the staff on a unit(RNs),licensed practical nurses(LPNs),NAs,and USs.It explores staff char-acteristics,staffing,and scheduling variables as they relate to the level of teamwork.The specific research questions for this study are the following
1)How does teamwork vary by hospital and/or type of
service?
2)How does the level of teamwork vary by staff char-
acteristics(i.e.,age,gender,ethnicity,education,and experience)of team members?
3)How does the level of teamwork vary by work
schedules(shift worked,length of shift,weekly work hours,and overtime)of team members?
4)How does the level of teamwork vary by number of
assigned patients and perceptions of the staffing adequacy?
Previous Studies
Most of the research on teamwork in health care has focused on primarily in emergency and intraoperative settings(Makary et al.,2006;Morey et al.,2002;Salas, Rosen,&King,2007).There have been studies in-volving nurses which have dealt with interdisciplinary teamwork.For example,Rafferty et https://www.wendangku.net/doc/5a6201568.html,pleted a survey of staff nurses in32hospitals in England to explore the relationship between interdisciplinary team-work and nurse autonomy on patient and nurse out-comes and nurse-assessed quality of care(Rafferty,Ball, &Aiken,2001;Rafferty et al.,2007).They found a strong association between teamwork and autonomy (Rafferty et al.,2001).McCallin and Bamford(2007) emphasized the importance of emotional intelligence that impacts on social and team effectiveness and the outcomes of care.A survey study of physicians and nurses in intensive care showed a major discrepancy between the attitudes of the two groups.Nurses rated teamwork lower than did physicians(Thomas,Sexton, &Helmreich,2003).
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324Health Care Management REVIEW
Few studies have explored intraunit nursing team-work.There have been a handful of studies that have tested methods of increasing nursing teamwork(Amos, Hu,&Herrick,2005;Britton,1984;DiMeglio et al, 2005).Another small group of studies has focused on the relationship between teamwork and nurse retention. Two studies have shown work environment,job satis-faction,social networks,and interpersonal relationships to be factors in nurse retention(Parsons&Stonestreet, 2004;Toofany,2007).For example,according to Lavoie-Tremblay,O’Brien-Pallas,Viens,Brabant,and Gelinas (2006),the leading characteristics of healthy work environments leading to work satisfaction and retention include a culture of teamwork,a sense of community, respectful and collaborative communication,and ade-quate social support from colleagues.Also,a study with 28,561nurses in Europe showed that teamwork is as-sociated with nurses’decision to leave the profession, nurses’job satisfaction,quality of care,and burnout (Estryn-Behar et al.,2007).They reported that improv-ing collaboration and multidisciplinary teamwork can prevent premature leaving(Estryn-Behar et al.,2007).
A number of studies have linked teamwork and pa-tient outcomes.For example,a group culture,charac-terized by affiliation among all levels of hospital staff, was predictive of fewer patient falls with injury(Brewer, 2006).Wheelan,Burchill,and Tilin(2003)found that units where staff members perceived they were func-tioning at higher levels of team development had lower mortality rates than team members on units with lower perceptions of team effectiveness.These higher func-tioning units also perceived that their teams were more structured and organized than did staff members of lower performing units.
Study Methods
Setting and Participants
This study was conducted in a large academic health science center of943beds and in a community hospital of120beds in2008.Participants were RNs,LPNs,NAs, and USs who worked on38patient care units—27in adult medical–surgical and intensive care and11units in pediatrics and maternity.A total of1,802nursing staff participated in the study.Once cases were removed that could not be utilized(i.e.,staff did not spend most time on the unit,too many omitted items,etc.),the sample size was1,758.
Of these1,758participants,87.2%(n=1,533)were women,most worked full-time(79.5%,n=1,397),and approximately half held a baccalaureate degree(48.2%, n=848).More than half of the staff members were between the ages of26to44years(56.5%,n=993).The average number of years of work experience in nursing was9.85.The vast majority of the participants (77.4%,n=1,360)reported their job title as nurse(e.g., RN and LPN);11.9%(n=210),NAs;and7.9%(n= 139),USs.Nursing staff survey respondents worked on a variety of types of units:30.3%(n=532)intensive care units(ICUs),of which17.2%(n=302)were adult ICUs and13.1%(n=230)were pediatric ICUs;11.7% (n=205),adult intermediate-level units;28.7%(n= 505),adult medical–surgical and rehabilitation units; 13%(n=228),pediatric units;6.8%(n=119),emer-gency departments and related units;5.7%(n=101), maternity units;and3.8%(n=67),other units. Study Instrument
The survey instrument utilized in this study was the Nursing Teamwork Survey(NTS),a33-item question-naire with a Likert-type scaling system from rarely(1)to always(5).The NTS is a newly developed survey de-signed specifically for inpatient nursing unit teams.The NTS was tested for its psychometric properties and are reported elsewhere(Kalisch,Lee,&Salas,2009).The survey items were generated from focus groups with staff nurses and managers(Kalisch et al.,in press)and a re-view of teamwork theories and research.The teamwork conceptual framework of Salas et al.(2005)described earlier was utilized as a basis for the tool.
Psychometric testing of the NTS involves measure of acceptability,validity,and reliability.Acceptability of the tool was high:80.4%of the respondents answered all of the questions,and another11.5%missed only one item.Validity of the NTS was tested in several ways. First,the expert panels who reviewed the survey on repeated occasions achieved a content validity index of .91on the final version,indicating considerable consis-tency among ratings of item relevance and clarity (Lynn,1986).Construct validity,tested with exploratory factor analysis,resulted in five factors:trust(7items), team orientation(9items),backup(6items),shared mental models(7items),and team leadership(4items). These five factors with33items in total explained 53.11%of variance.The result from the Bartlett test indicated that the correlation matrix is not an iden-tity matrix( 2=12,860.195,df=528,p<.01),and the Kaiser–Meyer–Olkin measure showed that sampling adequacy was excellent(.961).The next validity test was confirmatory factor analysis.The confirmatory fac-tor analysis showed that the33-item five-factor model fits the data very well.A comparative fit index of the model was.884,the root mean square error of approxi-mation index was.055,and the standardized root mean residual fit index was.045,which all indicate that the five-factor teamwork model resulted in a good model fit.Con-trasting group validity was demonstrated by the significant
Teamwork,Staffing,and Schedules325
differences between survival team nurses expected to score lower than do the other respondents because the tool was designed specifically for inpatient units.A comparison of scores on the Safety Attitudes Questionnaire (Sexton et al.,2006)subscale on teamwork and the NTS were correlated (r =.76,p <.01)as predicted.
For reliability tests of the survey,test–retest reliability was completed with a pilot sample of staff nurses (n =49).The overall test–retest coefficient with 33items was .92,and the coefficients on each subscale ranged from .77to .87.The overall internal consistency of the survey was .94,and the alpha coefficients on each sub-scale ranged from .74to .85.Intraclass correlation co-efficients and index of agreement (r wg(j))were also calculated to estimate interrater agreement for each unit staff group.These analyses demonstrated that members of the same unit responded similarly to the NTS and that staff on different units responded differently.This allows the tool to be used as a unit-level variable.
Procedures
After institutional review board approval,the study was initiated by seeking permission of the patient unit man-agers in the two facilities.All of the units in the two facilities agreed to participate in the study.The NTSs were distributed to the nursing staff,with a cover letter containing consent information and instructions.All surveys were anonymous.The nursing staff were asked to place the completed survey in a sealed envelop and then into a locked box placed on the unit.Incentives to participate in the study included a candy bar with each survey.Units with a 50%or higher return rate were given a pizza party.
Data Analysis
Analyses were completed using the Statistical Pack-age for the Social Science,Window Version 16.0(SPSS,Chicago,IL).After data cleaning,preliminary analyses of the data were completed using frequency,descriptive,independent-sample t test,one-way analy-sis of variance,correlation,and chi-square methods according to the research questions.Multiple regres-sion analysis was employed to determine the impor-tant predictors of nursing teamwork overall as well as the five subscales.The ‘‘enter’’method was used to enter all significant variables from the prelimi-nary analyses at the same time.In this simultaneous model,each independent variable is evaluated in terms of its predictive power,over and above that of-fered by all the other independent variables (Pallant,2005,p.141).
Results
Variation by Hospital and Service
The NTS overall score and four out of five subscale scores were significantly different by type of hospital:trust,t (161.421)=à2.042,p <.05;team orientation,t (1755)=à2.769,p <.01;backup,t (1755)=à2.922,p <.01;shared mental models,t (1756)=à4.099,p <.001;and the overall score,t (162.625)=à2.805,p <.001.The community hospital scored higher on trust (3.63±0.82),team orientation (3.59±0.75),backup (3.76±0.73),shared mental models (4.18±0.61),and the overall score (3.78±0.65)than did the academic
Table 1
Nursing teamwork scores by service types (N =1,758)
Teamwork overall
Trust
Variables and categories
n
M ±SD
F M ±SD
F Service types 22.52**
13.10**
Adult ICU
302 3.72±0.50ab
3.59±0.63ab
Adult intermediate units 205 3.68±0.50cd
3.55±0.68cd Adult medical–surgical units
505 3.42±0.59acefgh 3.33±0.72acefg Emergency,survival flight,and transport 119 3.39±0.66bdijkl 3.18±0.75bdhijk Maternity units 101 3.79±0.60ei 3.66±0.69eh Pediatric ICU 230 3.77±0.46fj 3.54±0.64fi Pediatric units 228 3.83±0.44gk 3.72±0.60gj Other units
67 3.83±0.74hl 3.60
±0.95k
Note .Groups with the same letter are significantly different according to Bonferroni post hoc test.ICU =intensive care unit.*p <.05.**p <.01.
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326Health Care Management REVIEW
health center(3.48±0.69,3.42±0.70,3.58±0.70, 3.98±0.57,and3.62±0.56,respectively).
Table1shows that significant differences were found in the NTS overall score,F(7,1749)=22.519,p<.001,and the five subscale scores by service types:trust,F(7,1747)= 13.098,p<.001;team orientation,F(7,1748)=14.405,p< .001;backup,F(7,1748)=22.063,p<.001;shared mental models,F(7,1749)=18.052,p<.001;and team leadership, F(7,1745)=21.366,p<.001.Post hoc analysis revealed that the following types of units ranged from highest to lowest teamwork:maternity,pediatric,and other units; intensive and intermediate care next;adult medical–surgical units;and finally,emergency,survival flight,and transport teams.More specifically,the medical–surgical units not only had the second lowest overall teamwork score and on four of the five subscales scores,but they also had the lowest score on backup(p<.05).
Staff Characteristics
Scores on the NTS were tested for differences by age, gender,ethnicity,education,and experience.No differ-ences were found by ethnicity or education.However, the teamwork overall and the shared mental models subscale scores were significantly different by gender, with men reporting lower(3.54±0.61and3.90±0.74, respectively)and women higher teamwork(3.64±0.57 and4.00±0.57,respectively),t(1687)=à2.080,p< .05,and t(1687)=à2.236,p<.05,respectively.The shared mental model score was also different by age, with the older group reporting higher shared mental models scores,F(4,1744)=2.720,p<.05.Post hoc analysis revealed that the55-year-old and older group scored the highest on shared mental models(4.11±0.60),which was significantly different from the35-to 44-year-old group(3.96±0.62;p<.05).
As seen in Table2,staff with less than6months ex-perience scored highest on teamwork overall,F(4,1713)= 2.971,p<.05,and on the subscales of trust,F(4,1711)= 2.899,p<.05;team orientation,F(4,1712)=5.400,p< .001;and shared mental models,F(4,1713)=2.573,p< .05.For experience on the current unit,again,the staff with less than6months experience reported higher levels on the overall teamwork score than did those with more years on the unit,F(4,1696)=7.153,p<.001.The lesser experienced staff(under6months)also reported higher levels of trust,F(4,1694)= 5.033,p<.001);team orientation,F(4,1695)=9.289,p<.001;shared mental models,F(4,1696)=4.473,p<.01;and team leadership, F(4,1692)=5.193,p<.001.Only the teamwork subscale backup did not vary by experience on the unit. Schedules
Significant differences between the four categories of shift worked(day,evening,night,and rotating)were evident in the overall teamwork score,F(3,1741)= 4.38,p<.01.As can be seen in Table3,the subscales of backup,F(3,1740)=8.58,p<.001,and team leadership, F(3,1737)=3.20,p<.05,were also significantly dif-ferent.Post hoc analysis revealed that the night shift group had the highest scores on backup and team lead-ership,with the day shift and the rotating staff reporting the lowest level of teamwork(p<.05to p<.001).
For the length of shift variable,only the subscale of team leadership was found to be significantly different, with those working8or10hours per shift reporting the highest level of teamwork(3.83±0.72)and staff working
Team orientation Backup Shared mental model Team leadership
M±SD F M±SD F M±SD F M±SD F
14.41**22.06**18.05**21.37** 3.55±0.65ab 3.62±0.69ablm 4.08±0.50ab 3.86±0.66ab
3.47±0.70cd 3.64±0.64cno
4.04±0.54cd 3.82±0.67cdk
3.22±0.74acefgh 3.33±0.73acdefg 3.80±0.63acefgh 3.52±0.76acefg
3.20±0.77bdijkl 3.38±0.77hijkln 3.79±0.68bdijkl 3.47±0.96bdhij
3.53±0.72ei 3.81±0.69dh
4.08±0.59ei 4.04±0.66eh
3.55±0.61fj 3.82±0.54eim
4.09±0.44fj 4.04±0.58fik
3.63±0.58gk 3.75±0.60fj
4.18±0.40gk 3.93±0.59gj
3.62±0.85hl 3.97±0.73bgko
4.25±0.80hl 3.78±0.95
Teamwork,Staffing,and Schedules327
a combination of 8-and 12-hour shifts having the low-est teamwork scores (3.61±0.67),F (2,1740)=5.963,p <.01.This difference was statistically significant ac-cording to a post hoc analysis (p <.01).Nursing staff working less than 30hours per week reported significantly higher scores than did those work-ing over 30hours per week in the overall team-work score,t (1739)=4.416,p <.001,and on all five
Table 2
Nursing teamwork scores by experience in the role and on the unit (N =1,758)
Teamwork overall
Trust
Variables and categories n
M ±SD
F M ±SD
F Experience in the role 2.97*
2.90*
6months
68 3.84±0.45ab
3.71±0.59a
>6months to 2years 339 3.65±0.55 3.53±0.70>2to 5years 374 3.62±0.54b 3.52±0.66>5to 10years 305 3.59±0.57a 3.42±0.73a >10years
632 3.65±0.60 3.47
±0.71Experience on the unit 7.15**
5.03**
6months
129 3.87±0.49abcd
3.74±0.65abcd
>6months to 2years 513 3.60±0.56a 3.48±0.71a >2to 5years 453 3.63±0.59b 3.50±0.71b >5to 10years 297 3.58±0.58c 3.42±0.71c >10years
309
3.67
±
0.56d
3.49
±0.68d
Note .Groups with same letter are significantly different according to Bonferroni post hoc test.*p <.05.**p <.01.
Table 3
Nursing teamwork scores by work shift,length of shift,weekly work hours,and overtime (N =1,758)
Teamwork overall
Trust
Variables and categories
n
M ±SD
F M ±SD F Shift worked 4.38**
2.31
Days 742 3.60±0.57a
3.45±0.69Evening 193 3.66±0.56 3.49±0.71Nights
453 3.71±0.57ab 3.56±0.70Rotating shifts
357 3.59±0.56b
3.48
±0.72
Length of shift (hours) 2.01
.02
8or 10668 3.66±0.57 3.49±0.7212or more
942 3.62±0.58 3.49±0.70Combined length 137 3.57±0.51 3.50±0.64
Weekly work hours 4.42**
2.44*
Less than 30344 3.76±0.53 3.58±0.6830or more
1397 3.61±0.57 3.47±0.71
Overtime work in last 3months (hours) 6.76**
3.81*
None 455 3.72±0.55ab
3.57±0.68a
1–12
662 3.60±0.55a 3.47±0.69More than 12
621
3.60±0.60b
3.46±0.73a
Note .Groups with same letter are significantly different according to Bonferroni post hoc test.*p <.05.**p <.01.
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328Health Care Management REVIEW
teamwork subscales:trust,t(1737)=2.438,p<.05;team orientation,t(1738)=4.817,p<.001;backup,t(1738)= 3.033,p<.01;shared mental models,t(1739)=3.509,p< .001;and team leadership,t(1735)=3.819,p<.001.
The nursing staff reporting no overtime in the last 3months had the highest teamwork scores overall, F(2,1737)=6.437,<0.01,and on all five subscales: trust,F(2,1735)=3.808,p<.001;team orientation,
Team orientation Backup Shared mental model Team leadership
M±SD F M±SD F M±SD F M±SD F
5.40**.52 2.57* 1.13 3.78±0.64abcd 3.68±0.55 4.14±0.48 3.93±0.61
3.45±0.69a 3.59±0.66 3.99±0.55 3.80±0.71
3.38±0.67b 3.59±0.71 3.97±0.55 3.74±0.71
3.38±0.72c 3.57±0.70 3.94±0.57 3.76±0.75
3.45±0.72d 3.59±0.74
4.03±0.60 3.78±0.77
9.29** 2.19 4.47** 5.19** 3.77±0.64abcd 3.73±0.62 4.17±0.51abc 4.02±0.61abc
3.40±0.69a 3.54±0.71 3.96±0.56a 3.72±0.74a
3.39±0.72b 3.60±0.75
4.01±0.59b 3.78±0.76b
3.37±0.71c 3.57±0.69 3.94±0.58c 3.71±0.74c
3.48±0.71d 3.62±0.67
4.02±0.58 3.82±0.70
Team orientation Backup Shared mental model Team leadership
M±SD F M±SD F M±SD F M±SD F
2.498.58** 2.41
3.20*
3.41±0.72 3.54±0.71a 3.96±0.58 3.74±0.74a
3.50±0.70 3.61±0.67
4.02±0.53 3.76±0.76
3.48±0.69 3.73±0.70ab
4.05±0.58 3.86±0.72ab
3.37±0.69 3.51±0.71b 3.96±0.59 3.72±0.74b
1.90 1.88 1.00 5.96** 3.47±0.72 3.32±0.69 4.01±0.58 3.83±0.72a
3.42±0.70 3.57±0.72 3.98±0.58 3.75±0.76
3.35±0.66 3.51±0.65 3.95±0.54 3.61±0.67a
4.82** 3.03** 3.51** 3.82** 3.60±0.66 3.69±0.69 4.09±0.53 3.91±0.71
3.39±0.71 3.56±0.71 3.97±0.58 3.74±0.74
4.47* 3.65* 6.07**
5.97** 3.52±0.70ab 3.66±0.69a 4.07±0.54ab 3.87±0.72ab
3.41±0.69a 3.55±0.71a 3.96±0.57a 3.72±0.73a
3.39±0.72b 3.57±0.71 3.97±0.60b 3.74±0.74b Teamwork,Staffing,and Schedules329
F (2,1736)=4.467,p <.05;backup,F (2,1736)=3.648,p <.05;shared mental models,F (2,1737)=6.069,p <.01;and team leadership,F (2,1733)=5.968,p <.01.
Staffing
As can be seen in Figure 1,those who feel that their unit staffing is adequate 100%of the time had the highest teamwork scores,whereas participants who rated the adequacy of staffing to be only 0%to 50%of the time
had the lowest teamwork scores.This finding was uniform across the five teamwork subscales (p <.01).In terms of the number of patients cared for on the most recent shift worked,only RN and LPN data were analyzed (Table 4).There were significant differences in the teamwork overall score,F (2,1523)=16.721,p <.001,and on four of five factors:trust,F (2,1523)=8.243,p <.001;team orientation,F (2,1522)=11.653,p <.001;backup,F (2,1523)=12.931,p <.001;shared mental models,F (2,1523)=11.692,p <.001;and team
Figure 1
Nursing teamwork scores by perception of adequacy of staffing (N =1,758)
Table 4
Nursing teamwork scores by numbers of patients cared for by nurses (n =1,360)
Teamwork overall
Trust Variables and categories
n
M ±SD
F M ±SD
F Numbers of patients cared for (only for nurses)16.72**
8.24**
Less than 3468 3.73±0.50a
3.57±0.63a
3
240 3.68±0.55b 3.55±0.67b 4or more
818 3.55±0.61ab 3.42±0.74ab
Note .Groups with same letter are significantly different according to Bonferroni post hoc test.*p <.05.**p <.01.
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leadership,F(2,1520)=21.238,p<.001.Nurses taking care of fewer patients rated teamwork higher.
Discussion
In this study of nursing teamwork in acute care set-tings,five subscales that emerged from this study fo-cus on selected aspects of teamwork framework of Salas et al.(2005).Five of the eight teamwork behaviors that emerged from the data and all of these fit well with the framework of Salas et al.Three of the eight teamwork behaviors of Salas et al did not emerge from the survey data—communication,adaptability and mu-tual performance https://www.wendangku.net/doc/5a6201568.html,munication appears to be a component of each of the other factors.Adapt-ability and mutual performance monitoring may have been considered components of the backup subscale. Further research will shed light on whether the theory of Salas et al.fits with nursing teams in acute care settings.
The result showed variation in scores between the two hospitals in the study.The community hospital scored significantly higher than did the academic health center in the NTS overall score and four out of the five subscale scores.Although we do not know for sure, the fact that the community hospital had undergone a project to increase teamwork and engagement on all of its patient care units(Kalisch,Curley&Stefanov,2007) may be the reason for the higher scores.
There were also differences by service type.On the basis of multiple linear regression analyses,working in medical–surgical units appeared to be the most signif-icantly related to the teamwork overall and the five subscale scores.The staff on medical–surgical units rated teamwork significantly lower than did the other units, including intensive care,pediatric,and maternity units. This finding is not surprising given the work environ-ment in the medical–surgical patient care areas where staff work a variety of shifts and come and go at different times.In addition,the structure of the unit is generally not conducive to teamwork in that there are long halls and incomplete line of sight.Also,these teams are typically very large,ranging from40to80individuals (Kalisch&Begeny,2006;Kalisch,Begeny,&Anderson, 2008),whereas the typical size of a team across in-dustries is8individuals(Kalisch&Begeny,2005).As Estryn-Behar et al.(2007)emphasized,developing unit designs which facilitate teamwork is important for the improvement of work processes through collaboration and multidisciplinary teamwork.They explained that a better agreement on work organization and informa-tion sharing reduces ambiguity and interruptions and might limit the need for overtime work.Druskat and Pescosolido(2002)also supported the importance of shared mental models among team members.
Males reported lower levels on the overall teamwork and the shared mental models subscale.Perhaps this is due to the minority position of male staff in nursing. They may not feel included or may communicate differently than the female majority of the staff.The oldest nurses reported higher levels on the shared mental models subscale,which may be due to their familiarity with professional standards,nursing practice, and team culture and their assumption that others also have this knowledge and skill.
It is interesting that staff with less than6months of experience in their roles and/or on the unit showed the highest overall teamwork and in four out of five subscales scores.These higher ratings of teamwork may be attributed to a number of possibilities:a strong ori-entation where nurses are mentored extensively dur-ing this time frame;a honeymoon effect with higher levels of motivation for those newly appointed;new nurses did not have exposure to the team to evaluate it accurately;they are so focused on their own perfor-mance and anxious about their ability to fulfill their
Team orientation Backup Shared mental model Team leadership
M±SD F M±SD F M±SD F M±SD F
11.65**12.93**11.69**21.24** 3.53±0.64a 3.69±0.65a 4.06±0.49a 3.92±0.63ab
3.48±0.73b 3.61±0.68
4.05±0.57b 3.76±0.71a
3.35±0.72ab 3.49±0.74a 3.92±0.62ab 3.65±0.78b
Teamwork,Staffing,and Schedules331
responsibilities that they are unable to evaluate team-work broadly;new nurses tend to have a lot of instances of needing assistance from the more experienced nurses, and receiving this assistance could cause them to evalu-ate teamwork high;and new nurses that observe that a more experienced nurse appears to work efficiently may conclude that everyone else has it together,even if it is not true.
Night staff report higher teamwork.This is consistent with previous work(Kalisch et al.,in press)where night staff in focus groups reported higher levels of teamwork. Possible explanations for this finding include that there are fewer people around at night and smaller teams find it easier to be high performing than do larger teams. Necessity has also been postulated in that they must work together to get the job done.Another reason may be that the staff are less stressed at night.
Nursing staff working less than30hours weekly re-ported significantly higher teamwork scores than did those working over30hours weekly.This finding is surprising in that research has shown that part-time employees do not feel as much a part of the team than do full-time staff(Rafferty et al.,2001).This difference may be due to the fact that those nurses working part-time are less stressed and/or tired than are those working less than30hours a week.They also may not have a full understanding of how the team functions because they have limited exposure to it.
Nursing staff who rate teamwork on their units higher have less overtime hours.This may be due to the fact that,when the team works together effectively,they work more efficiently.Studies have shown that efficiency improves with higher levels of teamwork(Druskat& Pescosolido,2002;Estryn-Behar et al.,2007).
The findings from this study show that teamwork is associated with fewer assigned patients and per-ceptions of good staffing.This suggests that teamwork may be enhanced by a decreased workload or it may mean that increased fatigue and stress lead to in-terpersonal and communication problems resulting in lower teamwork.
Limitations
This study is limited by the fact that data were collected in only two facilities.Further research is needed to determine if the findings of this study are the same in other settings.Another limitation may be that intra-personal characteristics were not collected which may impact teamwork.As Paris,Salas,and Cannon-Bowers (2000)described,individual traits of team members (e.g.,knowledge,skills and attitudes,competence,learn-ing ability,risk-taking propensities,tolerance for stress, etc.)would be required to facilitate team interactions and functioning.
Implications
The context of nursing teams(medical,surgical,inten-sive care,rehabilitation,oncology,pediatrics,maternity, perioperative,etc)has received scant attention,yet there are literally thousands of these teams,and they are having a major impact on the quality of care and patient safety worldwide.More attention and resources need to be applied to improving teamwork at the patient unit level in acute care hospitals.This could potentially im-prove quality,decrease errors,and save costs.
Traditionally,it has been assumed that,if an indi-vidual nurse is able to work independently,he or she would automatically be able to perform effectively as a team member or leader.Consequently,assessment and formal training in teamwork have been largely absent in organizations and basic nurse education programs (Leonard et al.,2004).Recently,the patient safety movement has focused on the need for teamwork.For example,the Quality and Safety Education for Nurse faculty(Cronenwett et al.,2007)emphasized teamwork and collaboration.This study suggests that it would be potentially cost-effective and quality enhancing to ad-dress this issue in organizations and devote resources to the improvement of nursing teamwork.What is needed is teamwork training and culture change efforts to move each patient care unit toward high-performing teamwork.
Acknowledgments
The authors would like to acknowledge Julie Juno,Laura Shakarjian,and Sue Wright for their work in assisting with the data collection and I-Wen Chang for her as-sistance with data analysis.
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