Ajeigbe, David O. PhD, RNC; McNeese-Smith, Donna EdD, RN, NEA-BC; Leach, Linda Searle PhD, RN, NEA-BC; Phillips, Linda R. PhD, RN
Shortages of healthcare personnel have accentuated the need for managers and hospital administrators to build environments conducive to recruiting and retaining staff. Nurses and physicians are considered integral members of most healthcare organizations. Studies in nursing and general healthcare literature have demonstrated positive associations between teamwork and job environments, autonomy, independence, work discretion, and control over practice.1-3 It is essential to study elements such as teamwork that could improve staff retention and nurse-physician relationships in the emergency department (ED). Therefore, this study focused on teamwork in the EDs because of the paucity of data validating the value of teamwork in this high-visibility department, particularly in relation to job environment, autonomy, and control over practice.
The purpose of this cross-sectional study was to compare perceptions of ED nurses and physicians about their job environment, autonomy, and control over practice among staff from EDs that had previously undergone formal teamwork training and who stated that they were actively practicing teamwork strategies and staff in EDs that did not participate in formal nurse-physician teamwork training and were not actively practicing principles of teamwork. This 1-time, postinterventional evaluation occurred approximately 2 to 4 years after the implementation of teamwork training and principles in the interventional departments.
The Value of Teamwork
Previous research data support that the perception of the presence of teamwork was affected by the shift and the part-time or full-time status of the nurse.2 In 1 study, 28% of day shift nurses and 16% of night shift nurses perceived the presence of teamwork on their shifts. A larger number of full-time nurses (27%) felt that their unit practiced teamwork than did their part-time counterparts (21%). According to the study, teamwork appears synergic with autonomy, and nurses who scored lower in perception of teamwork also scored lower in perception of autonomy; conversely, nurses who scored higher in their perceptions of teamwork scored higher in autonomy. The study also demonstrated the impact of teamwork training and practice on nurses’ rating of the effect of teamwork. After teamwork training and practice, 29% of the nurses rated nursing care quality on their units as excellent, 55% rated it good, and 14% rated it fair.4 Another study reported training as a positive intervention to support teamwork.5 An interventional study to increase the practice of teamwork and staff engagement showed decreased staff turnover, reduced vacancy, and improved teamwork.6 Although great strides toward teamwork practice in healthcare have been made, there is still a large body of knowledge on the strategy that has not been realized.7
External and internal influences appear to have effects on team autonomy. One example of an external influence is organizational intrusion on a team’s empowerment. This can include the inability to make independent operational decisions without previous consultation with higher managers. Therefore, internal influences are more likely to have positive relationships with teamwork quality, mutual support, cohesion, autonomy, and balance of team members’ contributions.8
Stability in staffing reflected in high levels of retention appears necessary to maintain group cohesion and teamwork. Group cohesion enhanced the nurses’ interests in assisting colleagues to handle stressful patient issues.9 Conversely, unit-based team-building strategy has been associated with improved group cohesion.1 After the introduction of unit-based team building, nurse-nurse interaction scores improved (from 68% to 71%); nurse-physician interactions improved (from 58% to 59%); the decision-making mean score improved (from 47% to 49%); perceptions of autonomy improved (from 48% to 53%); job enjoyment increased (from 51.26% to 56.58%); and turnover decreased (from 9% to 6%).1
Other factors including work-group cohesion, autonomy, promotional opportunities, work and family conflicts, supervisor support, variety of work, distributive justice, and organizational constraints predicted more than 40% of nurse job satisfaction.3
Donabedian’s Structure-Process-Outcome Model
The theoretical framework used as a foundation for this study is based on Donabedian’s structure-process-outcome (S-P-O) model of quality care.10,11 Donabedian’s theory posits that organizational healthcare structures affect processes of care, and processes of care thus influence patient outcomes. According to the theory, S-P-O are linked to form the 3 components of quality assessment. Donabedian contended that good structures increase the possibility of good processes, and good processes enhance good outcomes.10,11 Applying Donabedian’s model to this study shows the relationships between teamwork training/practice among physicians and nurses and their perceptions of the job environment, autonomy, and control over practice (Figure 1).
The design of this study is a comparative analysis of the effects of teamwork education and practice on staff, including registered nurses (RNs) and physicians (MDs), in EDs. Data were collected from 4 hospitals that were actively using the training from an emergency team coordination course (ETCC) in practicing teamwork versus 4 hospital EDs that have not participated in the ETCC course.
The ETCC was introduced in EDs by Morey et al,12 and the effect of the course on teamwork training was evaluated from May 1998 to March 1999. The training was an adaptation of an aviation-oriented teamwork curriculum to train staff in EDs who face similar life and death circumstances as those in aviation. The training addressed the following 5 team dimensions/principles: (1) maintaining team structure and climate, (2) applying problem-solving strategies, (3) communicating with the team, (4) executing plans and managing workload, and (5) improving team skills.
An RN and an MD were paired together as instructors for each group. Each group was composed of a mixture of nurses and physicians. After the training, each interventional ED created a staffing pattern based on a team concept with a mixture of nurses and MDs in each group. Each interventional ED implemented the training (ETCC) in their operational programs for new staff.
Emergency departments in California that have undergone similar formal teamwork training and were actively using its principles in their EDs, in either Northern or Southern California, were members of the interventional group (n = 4) and those that have never participated in formal teamwork training (ETCC) and were not using its principles in their EDs, in either Northern and Southern California, formed the control group (n = 4). Both groups were invited to participate in the study, and 8 hospital EDs in Northern and Southern California that agreed to participate in the study formed the interventional and control groups. Institutional review board approval was received from University of California, Los Angeles, and from each of the 8 participating hospitals in California.
Participants were a convenience sample of RNs and MDs from all shifts of each of the 4 interventional hospital EDs and from all shifts of each of the 4 control hospital EDs. All RNs and MDs were invited to participate and to complete survey questionnaires. The sample inclusion criteria were as follows: (a) staff (RNs and MDs) who have worked in the ED for at least 6 months and (b) staff who were full- or part-time. Those who did not meet the criteria were excluded. The purpose of the study was communicated to the participants, and they were given an opportunity to participate or to refuse. Accepting, completing, and returning completed questionnaires constituted consent to participate. Each participating hospital was assigned an identification number to maintain anonymity. Data were collected over a 3-year span (2009-2011) for a 7-day period in each participating facility. The staff demographic data collected included age, gender, educational level, work/employment status, and shift worked.
In the interventional group, 191 staff participated, 166 (87%) RNs and 25 (13%) MDs. Most were women (126, 66%), with a mean (SD) age of 38.4 (9.67) years, and had a mean (SD) years of working in the participating ED of 6.3 (6.42). About 48%, 27%, and 10% of the participating ED staff worked day, evening, and night shifts, respectively, and the participants also had various educational levels (See Tables, Supplemental Digital Content 1, http://links.lww.com/JONA/A194, and Supplemental Digital Content 2, http://links.lww.com/JONA/A195). In the control group, 307 staff participated, 267 (87.0%) RNs and 40 (13%) MDs. A total of 211 (69%) were women and 84 (27%) were men; mean (SD) age was 39.3 (10.61) years, and the mean (SD) years of working in the participating ED was 6.8 (5.80). About 39%, 23%, and 29% of the participating ED staff worked day, evening, and night shifts, respectively, and participants had various educational levels (See Tables, Supplemental Digital Content 1, http://links.lww.com/JONA/A194, and Supplemental Digital Content 2, http://links.lww.com/JONA/A195). There were no significant differences demographically between the interventional and the control groups (age, P = .16; gender: male/female, P = .40; employment category: RN/MD, P = .49; educational level, P = .25; full-time/part-time, P = .55; day/evening/night shift, P = .16) (See Table, Supplemental Digital Content 1, http://links.lww.com/JONA/A194).
The Healthcare Team Vitality Instrument (HTVI) was used to measure staff perceptions of the job environment. This 10-item instrument was developed as a part of a national program of Robert Wood Johnson Foundation and the Institute for Healthcare Improvement called Transforming Care at the Bedside.13
The HTVI is a short 5-point Likert-type survey measure, with response options ranging from 1 to 5, with 1 being strongly disagree and 5 being strongly agree. This instrument has been used in inpatient hospital settings such as medical-surgical units. It measures frontline staff perception of team vitality, empowerment and engagement, effective communication, team collaboration, and job environment supportive of safe and high-quality patient care. Construct validity of scale (extent to which HTVI measures the variables that it is intended to measure) was demonstrated by a coefficient of 0.90 or greater with a reliability of 0.80 to 0.90. This instrument measures not only the characteristics of the staff and their perceptions of the characteristics of the organization where they work but also critical factors of interdisciplinary team functioning.14
The Revised Nurse Work Index (NWI-R) was used to measure autonomy and control over practice.15,16 Psychometric information about NWI-R was described by Aiken and Patrician,17 and reliability was estimated using Cronbach’s α, which equaled .96 for the entire NWI-R; the aggregated subscale α values ranged from .84 to .91. The original instrument demonstrated validity by its ability to differentiate nurses who worked within a professional practice environment from those who did not and its capacity to predict differences in nurse burnout.17 When revised to measure MD job satisfaction, every word nurse was changed to physician and every word referring to nursing was changed to medical.
The Statistical Analysis Systems program, release 9.2 (SAS Institute Inc, Cary, North Carolina), was used for data analysis. The dataset was cleaned and typographical errors were corrected. Weighted averages derived by averaging all nonmissing values were calculated to account for missing values.
Descriptive statistical analysis was used for demographic variables. The analysis used the 2-sample, 1-sided t test to identify significant (P = .05) differences between the interventional and control groups.
Data on staff perception of job environment included access to resources, prompt response by support services, acceptance of openness to discuss challenging patient issues with team members, and feelings by team members that they could speak their mind, that their opinions and, more especially, staff feelings counted, and that there was free flow of patient care information among team members. Team vitality, empowerment and engagement, effective communication, teamwork, and job environment were collected using the HTVI. Measuring the above 5 issues, on a scale of 1 to 5, interventional group had a mean (SD) score of 4.01, (0.86), and the control group had a mean (SD) score of 3.75 (0.78). The t test showed a value of 3.25 (P = .0006), indicating a significant difference between the 2 groups; the interventional group scores were higher (Table 1).
Data on RN and MD autonomy were collected using the NWI-R (with a Likert-type scale of 1-4). The t test revealed a mean (SD) score of 3.27 (0.59) for the interventional group and 2.94 (0.61) for the control group (P < .0001), indicating a significant difference between the 2 groups (Table 1).
Control Over Practice
Registered nurse and MD perceptions of control over practice were measured using NWI-R on a Likert-type scale of 1 to 4; the interventional group had a mean (SD) score of 3.09 (0.73) and the control group had a mean (SD) score of and 2.86 (0.64). The t test revealed a value of 3.27 (P = .0006), indicating a significant difference between the 2 groups (Table 1).
Implementation of teamwork training and application of learning was potentially instrumental in better staff outcomes in the form of improved perceptions of the job environment, autonomy, and control over practice, as could be seen in this study. There was an association between perceptions of RN/MD teamwork and improved staff outcomes. There was a significant difference between the interventional and the control groups in staff perceptions of the job environment, including team vitality, empowerment and engagement, effective communication, and teamwork. Applying the t test to the mean scores of both groups demonstrated significant differences in staff perception of teamwork (P = .0006). The findings demonstrated that staff in the EDs that practiced teamwork (interventional group) perceived that there was effective communication, that their opinions were important, and that they were listened to by their superiors and counterparts. As a result, they felt empowered and were more engaged in the functioning of their EDs than were those staff who worked in the EDs belonging to the control group. Therefore, it could be concluded, based on the findings of this study, that effective RN/MD teamwork in the EDs appears to influence nurses’ and physicians’ perceptions of the positive nature of the job environment.
The study also explored the effect of RN/MD teamwork in the ED on staff perceptions of autonomy using the NWI-R for data collection. Perceptions of support, freedom to make decisions regarding patient care, and lack of intrusion increased the perceptions of autonomy in the interventional group ED staff, compared with their counterparts who worked in the control group EDs. Based on the findings, the interventional group ED staff perceived they had more autonomy than the control group ED staff. Staff in the interventional group perceived that their supervisory staff were supportive of them, that they were not put in a position of doing things against their judgment, and that they were free to make important patient care and work decisions (control over practice) without interference from their management staff. However, staff who worked in the control group EDs did not feel so positive about the amount of autonomy accorded them by their management staff. Study findings support those from a study by DiMeglio, which showed that implementation of a unit-based team-building strategy was associated with improved perceptions of autonomy from the preimplementation score of 48.26% to a postimplementation score of 52.98% (P = .05).
Differences in staff feelings of control over practice between staff who worked in the interventional group EDs and those who worked in the control group EDs were also tested. The interventional group ED staff felt that they had control over their practice based on the feelings that they had adequate support services to enable them to spend adequate time with patients, ample time to discuss patient care issues with other staff, and an adequate number of staff to provide quality patient care; that patient care assignments fostered continuity of patient care; and that they had good managers and leaders (P = .0006). On the other hand, staff who worked in the control group EDs did not feel that they had as much control over their practice.
The result of interpersonal relationships between the nurses and the physicians is one of the pieces of evidence of the effect of the ETCC, to make teamwork operational in the ED. The training focused on strategies to maintain team structure and climate, solve problems, maintain team communication, carry out plans and manage workload, and improve team skills.11,18 Based on the findings of the present study, it appears that the interpersonal relations between nurses and physicians significantly improved in the interventional group over the control group.
There was an association between RN/MD teamwork in the ED and staff perceptions of the job environment (P = .0006), autonomy (P < .0001), and control over practice (P = .0006). In all 3 variables, the interventional group staff had higher perceptions than did their counterparts who worked in the control group EDs.
The theoretical framework of this study, based on Donabedian’s S-P-O, indicated that structures, like the teamwork training program, would affect the processes of the ED that include supervisory support and staff communication, and the result would be better outcomes, such as perceptions of the job environment, autonomy, and control over practice. Although this research identified positive staff outcomes, it did not identify significant patient results; future research might further examine the relationship between improved staff outcomes and patient outcomes.
This study was conducted over a period of 3 years in multiple hospital EDs in Northern and Southern California. Despite the scope and multiple methods of data collection and analysis, there were certain limitations. First, the use of cross-sectional design did not allow for a longitudinal study of the effect of RN/MD teamwork in the ED on staff outcomes. Findings of this study are a snapshot of the effect of RN/MD teamwork in the ED on staff outcomes of both the interventional and control groups; therefore, findings of this study should be interpreted with caution. However, the positive results of the teamwork training had lasted 2 to 3 years. Second, this is a nonexperimental study that did not provide the ability to establish cause-and-effect relationships. Third, there was an inability to show that there were no other confounding variables (factors) such as similarities of the facilities or lack of similarities, accounting for the findings. Fourth, although 8 EDs throughout California participated in the study, the use of convenience samples might have contributed to a lack of generalizability.
This study showed the positive effects of RN/MD teamwork in the ED on perceptions of the work environment, autonomy, and control over practice setting for both MDs and RNs.
The results of this study pointed to the value of investing resources in RN/MD teamwork in the ED. Through teamwork, RNs and MDs could combine their expertise and coordinate good quality care to the patients while maintaining a positive environment for both disciplines to thrive.
This may affect patients’ outcomes, as well as staff enjoyment of the job environment. Although both RNs and MDs have common goals of providing quality healthcare and comfort to the patients, the traditional relationship between them has been that of MD dominance and of nurse deference.19-21 Nurses in a qualitative study expressed the need to state their information in such a way to be acceptable to not be summarily dismissed by physicians. The nurses also stated that their involvement in RN/MD decision making and problem solving was disrupted by the hierarchical status between nurses and MDs. In this form of hierarchical status, physicians’ inputs were more valued than the nurses’ inputs and communication between nurses and physicians was not considered as communication of equals and nurse’s contributions were often set aside.22,23 However, other studies showed that nurses are no longer having to accept subordinate positions in healthcare but are working as equal partners with MDs in patient care.19,24 Partnerships could be possible through genuine teamwork practice between the RNs and the MDs, not only in the ED but also in any healthcare setting that embraces genuine teamwork. Teamwork, preceded by effective teamwork training, could serve as an equalizer of hierarchies between the RNs and the MDs in the ED. Then, nurses and physicians could thrive in their individual roles and effective coordination would contribute to quality patient care.
The authors express their gratitude to Dr J.C. Morey, who introduced them to hospital EDs that had undergone his ETCC. His recommendations and support made it possible for some of those hospital EDs to participate in this study.
The authors also thank the nursing managers, nursing directors, physicians-in-charge, and medical directors for giving them permission to collect data in their institutions. The authors are very thankful also to the staff and patients of the 8 participating institutions for taking the time to participate in this study.
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