Abstract

Effective nursing teamwork has been linked to higher job satisfaction, less nurse turnover, better patient satisfaction, and better patient outcomes. The purpose of this project was to evaluate how a workflow process improvement program for acute care inpatient nursing units at a small community hospital would affect nurses’ perceptions of teamwork. The workflow changes included revisions of team player roles (charge nurse, RNs, LPN’s, and STNA’s), daily goals sheets, caregiver to caregiver report, and implementing unit huddles to improve communication.  A mixed methods approach was used to collect quantitative data using the Nursing Teamwork Survey to a convenience sample of all staff (RN’s, LPN’s, and STNA’s), as well as qualitative data from recorded focus groups, both which were administered before and 6 months after the changes were implemented. Results showed a significant decrease (t= 3.52, p<0.01) in overall perceptions of teamwork 6 months after the changes were implemented. This study discusses factors that may negatively influence teamwork on a nursing care unit and variables for nursing administrators to consider when making changes that affect nursing staff, as well as the importance of ongoing evaluation of workflow process changes in acute, complex-care environments.

Introduction

The increased emphasis on patient safety in hospitals has brought an increased understanding of the importance of teamwork in healthcare. Multiple research studies have confirmed that group teamwork among healthcare professionals leads to higher staff job satisfaction, increased patient safety, and greater patient satisfaction (Rafferty, Ball, & Aiken, 2001; Mickan& Rodger, 2000; Wheelan, Burchill, & Tilin, 2003; Gristwood, 2004; Meterko, Mohr, &Young, 2004). Unfortunately, many nursing teams are still a collection of individuals working independently who do not engage in effective teamwork behaviors such as monitoring one another’s performance, backing each other up, and engaging in communication and conflict resolution, (Clancy & Tornberg, 2007; Kalisch, Weaver, & Salas, 2009). Lack of teamwork and leadership can result in higher medical errors (Baker, Day, & Salas, 2006).With hospital reimbursement from Medicare now dependent upon patient satisfaction scores, organizations are looking to find work processes that are efficient and effective for both patients and staff needs. Kalisch, Curley, and Stefanov (2007) studied an intervention to increase teamwork and noted that although multidisciplinary teamwork has been well studied, there are few studies on the teamwork among nursing staff on a patient care unit.

Significance of Research

This study provides a real-life example of how the implementation of a new workflow on medical surgical units at a small community hospital negatively affected nurses’ perceptions of teamwork, and discusses ways for nurses and nursing administrators to become more aware of important factors that may affect the teamwork of a group of staff on a nursing unit.

Statement of Purpose

The purpose of this study was to evaluate how a workflow process improvement program for acute care inpatient nursing units would affect nursing staffs’ perceptions of teamwork. The intervention included revisions of team player roles (charge nurse, RN’s, LPN’s, and STNA’s), daily goals sheets, caregiver to caregiver report, and unit huddles to improve communication.

Nursing Conceptual/Theoretical Framework

The theoretical framework used in this research study is Salas, Sims, and Burke’s (2005) conceptual framework of teamwork which was chosen for its simple and practical view of various aspects contributing to effective teamwork. The Salas framework specifies 5 core components of teamwork: (1) team leadership (2) collective orientation (3) mutual performance monitoring (4) backup behavior and (5) adaptability. The theory suggests that leadership directly affects orientation, performance monitoring, and backup behavior. Relationships among teamwork concepts are fostered by 3 coordinating mechanisms according to the framework: (1) shared mental models (2) closed loop communication and (3) mutual trust.

Methods

At this facility, nursing administrators recognized a need to improve work processes in order to foster better collaboration of nursing staff and increase patient safety. A program was put together which included revision and clarification of team player roles (charge nurse, RN’s, LPN’s, STNA’s), daily goals sheets, caregiver to caregiver report, and unit huddles. The primary investigator was independently consulted in order to administer surveys and conduct focus groups, as well as report the results to nursing administration.A mixed methods research design was employed using a convenience sample of staff members (RN’s, LPN’s, and STNA’s).  Qualitative data was collected through focus groups before and 6 months after implementation of workflow changes. We recorded perceptions of staff (RN, LPN, STNA’s) at focus groups asking open ended questions using an MP3 player recorder.  This data was content-analyzed by researcher for recurring themes and patterns using Salas, Sims, and Burke’s (2005) framework. Conclusions were cross checked with focus group participants for accuracy. Quantitative data on nurse’s perceptions of teamwork was collected using the NTS (Nursing Teamwork Survey) by Beatrice Kalisch to all unit staff before and 6 months after the intervention. This instrument is based on Salas’s theory of teamwork and has demonstrated good validity and reliability in previous studies (Kalisch, Lee, & Salas, 2009). 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.

Definitions

Workflow Process ImprovementA 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). One specific change was that LPN’s would no longer have their own patient assignment (with an RN overseeing them), but rather would assist with the whole floor and pass medications on those patients delegated to them by the charge nurse. Due to this change, the LPN’s no longer charted assessments on any patients and the RN’s therefore had more patients to chart on. STNA’s and LPN’s were given daily goal sheets to use to make sure all required tasks were being done for every patient. LPN’s were no longer included in a group report for the whole floor at the beginning of the shift, but rather caregiver to caregiver (RN’s only) report was implemented, and then the charge nurse was to lead a unit huddle of all staff at the beginning of the shift to share pertinent information learned in report with the other team members, including LPN’s. Unit huddles are intentional meetings for 5-10 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.Nursing Teamwork SurveyThe Nursing Teamwork Survey (NTS) was developed by Kalisch, Lee, & Salas (2009) in order to differentiate levels of nursing teamwork on inpatient acute care facilities. The NTS has 33 questions using a 5 point Likert-scale that were allocated a point number as follows: Rarely = 0; 25% of the time =1; 50% of the time =2; 75% of the time = 3; Always = 4; The NTS has demonstrated good test-retest reliability (r= .92) and internal consistency (α= .94) (Kalisch & Lee, 2011). For this study, all surveys collected were scored and added up to get a grand total for each survey (maximum score = 132 which would demonstrate perfect teamwork). Any omitted questions on the surveys were scored with the number 2 (n=6).

Results

Pre-Intervention Surveys (n=50) included 36 RN’s, 9 LPN’s, 3 STNA’s, 1 Nurse intern, and 1 unmarked. 43 females, 4 males, 3 omitted for gender.  Primary shift: Days (40%, n=20); Evenings (36%,n=18);  Nights (20%, n=10); Rotate/Unmarked (4%, n=2)Post-Intervention Surveys (n=34) included 21 RN’s, 10 LPN’s, and 3 STNA’s. 30 females, 3 males, and 1 omitted gender. Primary shift: Days (53%, n=18); Evenings (41%, n=14); Nights (6%, n=2).Six months after the workflow changes were implemented, the average score for the NTS decreased significantly from 81.76 to 65.67 (st dev = 20.24, 20.95).  Independent Samples T-test indicated significance, T=3.52 (p<0.01). The focus groups provided valuable answers as to why teamwork was suffering.Focus Group Pre-Intervention (n= 6) 2 RN’s, 1 3 LPN’s, + 1 STNA- Before the workflow process changes were implemented, this focus group verbalized feelings of distrust with charge nurses and managers, and a lack of performance monitoring amidst the team. 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.Focus Group Post-Intervention (n=4) 1 RN, 2 LPN, and 1 STNA- Six months after the changes were implemented, staff verbalized that teamwork was worse now. 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. They noted an increased workload for the RN with the changes in LPN utilization. Many LPN’s felt devalued by the changes that had been made and were using passive resistance methods which created a negative working environment for other staff. 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.

Discussion

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.e. more RN’s in the mix of staff) has been linked to better teamwork (Kalisch & Lee, 2011). Since the workflow changes made in this study resulted in a higher RN to patient ratio (since the LPN’s no longer had a patient assignment), this alone could help explain why perceived levels of teamwork decreased.Poor teamwork can create nurse job dissatisfaction and lead to higher nurse turnover. According to Aiken et.al (2002), 42% of nurses dissatisfied with their jobs intend to leave within 12 months compared with 11% of nurses with high job satisfaction.  A negative work environment has also been linked to lower HCAHPS scores which will result in lower reimbursement for hospitals (Kutney-Lee et al., 2009). 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, (2002), 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. See Figure 1.

Triangle Teamwork

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. Managers and nursing administrators are urged to evaluate staff’s trust in leadership prior to implementing major changes affecting them, as well as including them in discussion and planning for changes involving their workflow.

Conclusions

A team’s adaptability to change is built upon the foundation of effective team leadership. 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.

Limitations

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.

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