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When Nursing Teamwork Suffers

Introduction

❶Medical Care, 42 5 ,

When Is Teamwork Effective?

Teams, Work and Teamwork


For instance, when people are working in a team, they have particular responsibilities that relate to their own specific skills and knowledge. One individual is always the leader, and this is agreed upon by the team or those who created it. In healthcare, teamwork is the ongoing process of interaction between team members as they work together to provide care to patients.

The researchers found that while teamwork and collaboration are often used as synonyms in casual discussion, they are not synonymous. Critically, the researchers identified inter-professional collaboration as both a process affecting teamwork and, in turn, patient care and health provider satisfaction and an outcome in and of itself.

In fact, collaboration can take place whether or not health professionals consider themselves to be part of a team. The researchers cite the example of primary healthcare, where professionals including a family physician, a physiotherapist and a dentist may all provide care to the same patient, yet in most cases do not see themselves as a functioning team.

On the other hand, effective teamwork rarely happens where there is no collaboration Oandasan et al. Teamwork requires an explicit decision by the team members to co-operate in meeting the shared objective. This requires that team members sacrifice their autonomy, allowing their activity to be coordinated by the team, either through decisions by the team leader or through shared decision making.

As a result, the responsibilities of professionals working as a team include not only activities they deliver because of their specialized skills or knowledge, but also those resulting from their commitment to monitor the activities performed by their teammates, including managing the conflicts that may result Oandasan et al. The CHSRF-funded team pulled together a strong evidence base for the characteristics of effective teams, and the evidence tells us that these teams adapt and respond to changing conditions.

Members of effective teams have faith in their ability to solve problems, are positive about their activities and trust each other. They can determine areas for improvement and reallocate resources to do so. And, of course, effective teams are often self-evident because they produce high-quality results. In healthcare, these include improved patient outcomes and cohesion, and competency or stability for the team itself. Outside of healthcare, research tells us that teams working together in high-risk and high-intensity work environments make fewer mistakes than do individuals.

This includes empirical evidence from commercial aviation, the military, firefighting and rapid-response police activities. These studies show a strong relationship between qualities such as flexibility, adaptability, resistance to stress, cohesion, retention and morale with effective team performance Baker et al.

In healthcare, studies have suggested that teamwork, when enhanced by inter-professional collaboration, could have a range of benefits. Although the link is far from definitive, it appears that teamwork and team composition could have positive effects, particularly in quality and safety Oandasan et al. These include reducing medical errors, improving quality of patient care, addressing workload issues, building cohesion and reducing burnout of healthcare professionals.

For example, a trial of team training for emergency room staff in US hospitals resulted in a reduction in clinical error rates from The CHSRF synthesis references a range of potential benefits from effective teamwork gleaned from selected teamwork initiatives:. Practical and well-evaluated plans for implementing teamwork are fairly rare, although Oandasan et al. For example, they note that patient safety studies have found that team training and decision aids such as checklists and communication protocols can be used to improve team processes and reduce adverse events Hoff et al.

In the United States, researchers looked recently at more than 20 years of research on specific techniques for building and training teams, which focuses on building appropriate knowledge, skills, and attitudes among potential team members in medical environments.

This review produced an extensive collection of guidelines relating to the content and style of team training programs Baker et al. In addition, a recent review of six medical team training programs concluded that crew resource management CRM , a team training model from the aviation field, has many important lessons to offer healthcare professionals, a point also noted by the CHSRF-funded team Baker et al.

So far, a few jurisdictions have developed customized healthcare CRM programs for teams in operating rooms, obstetrics, intensive care and emergency care. However, the delivery of medical team training across the healthcare community is "generally haphazard" Baker b. Broadly speaking, health human resources have been a preoccupation for managers and policy makers in Canada's healthcare systems.

Back in , those who were consulted as part of the first Listening for Direction national priority-setting exercise on health services and policy issues said clearly that health human resources would be the number one priority in the next two to five years Gagnon et al. With the exception of clinical organizations, which in were concerned about how new healthcare teams should be composed in order to meet the changing needs of patients, decision makers were preoccupied not with healthy workplaces or effective teamwork but with the supply of health human resources.

In particular, federal and provincial policy makers wanted to find mechanisms to help them to avoid cycles of surplus and shortage, while managers wanted to know about forecasting models that might help them plan for these cycles and employ retention and recruitment strategies.

In , teamwork came across as a major concern, primarily in clinical organizations. However, when the CHSRF and its partners repeated the Listening for Direction process in , a clear separation appeared between the workforce and workplace aspects of the issue, and concerns about teamwork were pervasive and prominent within both themes.

Within the workforce aspect were concerns about the best ways to facilitate inter-professional teamwork and approaches, as well as the regulation of scope of practice and entry to practice.

Within the workplace aspect was an interest in the role of occupational hierarchies, organizational structures and management practices and approaches and their effects on workplace productivity, stress, absenteeism and so on Dault et al. In other words, for Canadian decision makers, effective teamwork is a means to achieve improved quality and productivity for patients. For decision makers, it is a way to achieve a better balanced and more productive workforce but also one that is able to better serve the needs of patients.

Teamwork is seen as a way to improve quality of care for the patient, not only through improved efficiency but also through a happier and healthier workforce. Since the process, the Health Council of Canada has identified improving teamwork as a critical component to both accelerating system change Health Council of Canada a and improving human resource management Health Council of Canada b.

It is difficult to imagine who could oppose implementing effective teamwork as a way to improve healthcare. Even casual observers would likely equate the healthcare sector with teams and teamwork, and cite the history of nursing as an example.

However, in healthcare delivery, teams rarely exist that incorporate different professions and occupations, as well as patients and families. The greatest obstacle to change is arguably the hierarchical culture of healthcare. Entrenched attitudes about scopes of practice, professional "turf" and historical power structures can sabotage the essence of what teamwork is.

Providers need to address their personal power issues, adopt common goals, break down hierarchies and then educate patients about how each team member contributes to their care.

Formidable barriers that arise out of this culture include the self-regulation of professions, current malpractice and liability laws and funding and remuneration models. All these discourage and deter the establishment of teams.

For instance, current malpractice legislation places responsibility solely on individuals. Regulations that support teamwork, on the other hand, would refocus this "culture of blame" to a culture of patient safety and risk management. Much work needs to be done to clarify the accountability for non-physician team members in performing shared tasks. As for remuneration models, traditional fee-for-service payment systems for physicians impede movement toward collaborative care. What is more, no financial incentives exist that tie funding to collaboration and teamwork efforts, unlike initiatives in other countries such as England Oandasan et al.

In addition, significant and persisting supply issues continue to preoccupy both health workers and system managers and policy makers, and confound dedicated efforts to implement effective teamwork. The current shortage of some health professionals creates a pressure-cooker workplace environment where few people have the time, energy or will to experiment with new models of healthcare delivery.

To get a better picture of not only the challenges to implementing effective teamwork but also ways to overcome the challenges, the CHSRF convened a group of 25 researchers and decision makers in late to provide a forum for discussion about issues related to effective teamwork. The idea was to bring together experts from various perspectives with the goal of working toward tackling the issue and developing recommendations of how to implement teamwork at the differing levels of the healthcare system.

While a consensus was not expected, the aim was to secure a foundation based on current knowledge and evidence that would serve as a basis for evolving discussions and decisions in the future.

One major focus of the discussions was to identify why previous or existing efforts to implement collaborative practice in healthcare organizations had succeeded or failed to meet expectations. In particular, the experts around the table were asked the question, "Based on our knowledge and experience, what factors have underpinned success in implementing collaborative practice?

Conversely, the factors that would signal likely failure in implementing collaborative practice for the experts included the following:. The participants at the retreat identified particular challenges and opportunities for furthering the implementation of effective teamwork in the areas of management and policy. At the level of health system management, the participants at the CHSRF retreat felt the most serious challenges to inter-professional collaboration include a lack of designated responsibility for ensuring collaboration takes place.

History and tradition can serve as barriers as people often want to perpetuate the status quo, either to stay within their comfort zones or to protect vested interests. Ineffective communication can also be a critical barrier, unless multiple strategies are put in place to ensure effective communication within and between professions, as well as vertically within the institution. Finally, while project-based funding for collaboration can stimulate change at the project level, it does nothing at a systemic level, often making it difficult, or impossible, for change to become permanent and sustained.

To overcome the challenges at the organizational level, the experts recommended accreditation systems that outline clear requirements for inter-professional collaboration within organizations. In addition, they felt that dedicated funding for inter-professional collaboration would support a transition to, and ongoing review of, collaborative practice.

Also, more could be done in the area of intra-organizational knowledge transfer to help organizations share what they know about the results of research, demonstration site activities and learning projects. In the immediate future, the participants saw opportunities for organizational change in the areas of information and education.

On the information front, common measures of performance to monitor, evaluate or measure collaborative practice need to be developed. In addition, systems need to be implemented that capture, share, and link patient data, in order to facilitate collaborative practice. While they were sympathetic to concerns about privacy and confidentiality, the participants saw expanded access to patient information through electronic health records as a major facilitator of collaborative practice.

In addition, structures and a culture to value collaborative practice through organizational learning mechanisms should be adopted, particularly through continuing education. Finally, leadership training opportunities that include a collaborative practice component should be promoted within and across organizations. At the policy level, the primary challenges identified related to the difficulty of planning change across multiple jurisdictions and among many stakeholders.

Barriers to change include the territoriality of professions, as well as cross-sectoral professional issues such as liability and education. Within the policy context, the division between health and education programs at the provincial level was also seen as an obstacle, and one that governments are unlikely to address.

In general, participants felt that there is not a high degree of sustainability for any one issue or long-term planning, given that healthcare is highly dependent upon the priorities of current provincial governments.

Issues such as waiting lists and patient safety are currently dominating the policy agenda. While there may be some potential to reframe these issues as symptoms of systems that lack collaboration, this is a difficult task to undertake. Nonetheless, participants were optimistic about developments such as the pan-Canadian Health Human Resources planning framework, as well as two reports from the Health Council of Canada, which reference teamwork and collaboration Health Council of Canada a, b.

The work of the IECPCP was often cited and seen as a hopeful example of longer-term funding commitments that could assist policy change. In the immediate future, the participants called for a national policy forum on collaborative practice to be convened, including discussion on topics such as research and evaluation dimensions to best practices, lessons learned, return on investment, impacts of these projects, change in policy and policy buy-in.

Conclusions were cross checked with focus group participants for accuracy. SPSS statistical software was used to run statistics after the intervention.

Institutional approval was sought and given before beginning data collection. All staff members were invited to participate in surveys and focus groups. Focus group participants volunteered themselves and written consent was obtained, giving participants assurance that 1 only the researcher would have access to the audiotapes, for the purpose of evaluation of data; 2 no real names would be used in the analysis and study write-up; and 3 no names would be used that identified other coworkers or colleagues.

Each participant agreed to maintain the confidentiality of focus group content. Staff self-selected to participate in quantitative data collection by filling out an anonymous NTS survey. A program of changes determined by nursing administration which included revision and clarification of roles of team members, the use of daily goals sheets, RN to RN report instead of charge nurse giving report on all patients on the floor, and implementing unit huddles to improve communication.

Staff attended mandatory educational in-services conducted by nursing administrators which reviewed job descriptions and duties for the various types of nursing staff Charge nurse, RN, LPN, and STNA. Unit huddles are intentional meetings for minutes of all unit staff in order to share important patient information and promote effective teamwork.

Charge nurses were encouraged to lead unit huddles at the beginning, middle, and end of each shift as time allowed to share important patient information with the team and plan for the shift. The NTS has 33 questions using a 5 point Likert-scale that were allocated a point number as follows: Six months after the workflow changes were implemented, the average score for the NTS decreased significantly from The focus groups provided valuable answers as to why teamwork was suffering.

They perceived a lack of effective leadership and accountability, and were upset that the workflow process changes were decided by senior management without any input from staff. They noted that the unit huddles were not happening regularly due to non-compliance of staff, which resulted in poor communication and lack of team orientation. The focus group concluded that the changes made were not followed up to make sure staff understood and complied.

There was a lack of effective leadership from charge nurses and managers for follow through with accountability for the changes. Nursing teams were not effectively adapting to the new changes in the work environment.

This particular study demonstrates that changes made in the absence of effective leadership are doomed to face resistance and dissatisfaction from staff. As the Salas theory suggests, the leaders of the team directly affect whether the group is team orientated or not, and whether they can effectively monitor and correct performance issues.

Higher levels of nurse staffing and a higher proportion skill mix i. Poor teamwork can create nurse job dissatisfaction and lead to higher nurse turnover. According to Aiken et. For these reasons, nurse managers and administrators are urged to consider ways to improve teamwork through educational opportunities on communication and conflict resolution, team building exercises, and leadership development for charge nurses.

According to Lencoioni, , there are five dysfunctions which cause teams to fail including the absence of trust, fear of conflict, lack of commitment, avoidance of accountability, and inattention to results. In this particular study, the absence of trust was noted in the focus groups before the changes were implemented. There was a lack of commitment to the changes by the staff since they were not included in the decision-making surrounding these changes.

Since the unit huddles that were supposed to be happening were not being enforced, there was a lack of accountability to make sure people followed through with the workflow changes. Inattention to results happens when there is a lack of evaluation.

The evaluation of teamwork at this particular facility resulted in nursing administration being able to take action to promote teamwork and repair relationships with staff before the situation got worse. Nurse administrators need to model teamwork by including staff in discussions and decision making in order to build trust before implementing changes which affect their workflow.

Accountability and ongoing evaluation of workflow changes is imperative for goal attainment, as well as to ensure best staff and patient outcomes. This study was conducted at a small community hospital and used a convenience sample of nurses who self-selected to participate, so results must be understood in light of that.

The staff had already been educated about the coming workflow changes when the first focus group was held, so the anxiety of impending changes may have skewed results.

In a complex, acute-care environment, multiple processes are usually being changed at one time and therefore it was difficult to control for external variables.

The focus groups had limited participants so conclusions cannot necessarily be generalized to whole group of staff. Further research is needed to confirm effective techniques for nurse administrators to use for nursing team-building. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction.

Journal of the American Medical Association, 16 ,


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The CHSRF has made the management of the healthcare workplace one of its key research themes, and effective teamwork and inter-professional collaboration - with a focus on the role of occupational hierarchies, organizational structures and management practices and approaches and their effects on workplace productivity, stress and .

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The importance of teamwork can be explained in a way that it “builds morale and actually results in getting more accomplished with the resources you have because the team members develop ownership of the solution to a problem and want make it work” (Lindh et al., , p. ).

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The purpose of this systematic review and meta-analysis was to quantify the effects of the extant controlled experimental research of teamwork training interventions on teamwork and team performance. We found positive and significant medium-to-large sized effects for these interventions on teamwork and large effects on team performance. In addition, true teamwork and learning to problem solve as a team, builds communication skills. Through the building of communication skills, a team is able to share ideas, and provide useful feedback.4/4(1).