The Relationship between Teamwork Attitudes and Caring Behaviors among Nurses Working in Surgical Clinics: A Correlational Descriptive Study : Nigerian Journal of Clinical Practice

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Original Article

The Relationship between Teamwork Attitudes and Caring Behaviors among Nurses Working in Surgical Clinics

A Correlational Descriptive Study

Çelik, G Küçükakça; Taylan, S; Güven, ŞD; Çakir, H; Kiliç, M; Akoğlu, CA

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Nigerian Journal of Clinical Practice 22(6):p 849-854, June 2019. | DOI: 10.4103/njcp.njcp_623_18
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Due to the increased costs in modern healthcare services and the complexity of technological developments, it is essential to identify and coordinate manpower and financial resources to accomplish quality patient care outcomes.[1] Healthcare professionals make and implement joint decisions to achieve quality patient care outcomes. In addition, certain professions demand certain responsibilities. No one can be expected to do an unassigned work, and members of a profession are only responsible for the work they are obliged to do. Yet the input from the different professions plays important role in total patient care. This situation causes healthcare professionals to work in coordination.[2]

A team-based nursing caring approach is necessary to provide quality patient care. And to achieve successful results in patient care, each team member needs to play a critical role.[3] This is because quality patient care cannot be provided without an effective collaboration among team members. As a matter of fact, in a study carried out on organizations using team collaboration strategies, there was a significant improvement in patient care through effective teamwork, showing the importance of teamwork.[4]

The term team is defined as a group of two or more people with a common and valuable goal who interact dynamically, reciprocally, and harmoniously.[56] The term “healthcare team” is a group of health professional consisting of two or more individuals with expert knowledge and sharing goals such as making decisions, carrying out interdependent tasks, and offering safe and feasible care for patients.[7] An effective healthcare team shares clearly defined common goals and has a functional team leader; the team members communicate effectively and are harmonious and respectful to one other.[189] Therefore, an effective healthcare team is a team, also involving patients, in which members communicate with each other and unite their observations, experiences, and decision-making responsibilities to optimize patient care.[9] An effective team can help nurses achieve the goal of providing safe, efficient, and quality healthcare to their patients. In addition, nurses, each working as an effective team member, tend to make fewer mistakes than those who do not work with a team.[10] A study on teamwork has shown that teamwork enhances patient safety and reduces mortality.[11] Purdy et al. have stated that teamwork is one of the fundamental processes used to provide safe and effective patient care and that providing safe and effective patient care should be one of the top-priority goals of patient care teams.[12]

One of the areas where teamwork is highly necessary is surgical clinics. Nurses working in such places provide nursing care for complicated cases requiring attention and close observation due to the fact that patient circulation is rapid. Therefore, today, surgical clinic nurses need to work in teams for quality patient care.[13] The literature indicates that especially in the past two decades, the healthcare services have changed very rapidly; as a result of this change, modern healthcare services have become complex, becoming a driving force in the need for healthcare professionals to create a team spirit that shares a common goal.[6] In the US National Guideline Clearinghouse, currently more than 2,700 clinical practice guidelines are listed. Moreover, every year the results of more than 25,000 new clinical trials are published.[14] According to these results, it does not seem possible for a single practitioner to address all this information and reflect it on patient care. It becomes necessary for team members to have special knowledge in different care areas of patient care.

It has been reported in the literature that teamwork in nursing improves job satisfaction by bringing together team members and creating synergy.[1516] It is stated that experienced nurses with increased job satisfaction improve the quality of caring behaviors by providing adequate supervision and counseling for less experienced nurses.[317] The nursing profession, which is part of healthcare team members, is a profession that serves human beings directly. Care provided by nurses constitutes a large part of healthcare offered to patients. Thus, it is one of the most important factors affecting patient satisfaction. For these reasons, it is important to determine the relationship between teamwork and caring behaviors of nurses.


This study was carried out to determine how teamwork attitudes of nurses working in surgical clinics affect their caring behaviors.


In this study, answers to the following questions were sought:

  1. What are the teamwork attitudes of nurses according to Teamwork Attitudes Questionnaire (TAQ) and its subscales?
  2. What are the caring behaviors of nurses according to Caring Behaviors Inventory-24 (CBI-24) and its subscales?
  3. What is the relationship between nurses' teamwork attitudes and caring behaviors?.


The study was a correlational descriptive study. The study was carried out between February 1, 2018, and June 30, 2018. It was carried out on nurses working in the surgical clinics (four surgical clinics, emergency service, general intensive care, cardiovascular surgery intensive care, operating room, and pediatric surgery clinic) of a provincial state hospital in the Central Anatolia Region of Turkey. Inclusion criteria were as follows: (1) voluntary participation in the study and (2) working in one of the surgical clinics. Nurses who did not accept the study and who worked outside the surgical clinics were not included in the study sample.

The research population consisted of 126 nurses working in the surgical clinics of a provincial state hospital in the Central Anatolia Region of Turkey. A sample selection was not performed in this study. The study was carried out on 116 nurses who agreed to participate in the study. During the study, 92% of the population was reached.

Data collection

Before conducting the study, ethical approval was received from University Ethical Committee (date: 01.04.2018, issue: 01) and institutional approval from the State Hospital (date: 01.24.2018, issue: 55831188604.02). The nurses were informed about the purpose of the study. They were informed that the data obtained from the study would be confidential and would not be shared with anybody and that their privacy and unanimity would be protected. They were given “Informed Consent Forms,” and their consents were obtained.

The data were collected using a sociodemographic questionnaire/information form, TAQ, and CBI-24. The study questionnaires were given to nurses to be answered in a private room. The questionnaires were completed in 20–25 min.

A questionnaire/information form prepared by the researchers through a literature review consisted of 11 questions to determine the nurses' age, gender, marital status, educational status, clinic of employment, duration of employment in the profession, duration and style of employment in the current unit, total weekly working hours, average daily number of patients cared for, and status of receiving training on teamwork.[21017181920]

TAQ was developed by Baker et al.[7] to determine the attitudes of individuals about teamwork. The validity and reliability study of the Turkish version of the scale was carried out by Yardımci et al.[16] TAQ has 5-point Likert-type items with the following options: strongly disagree, disagree, undecided, agree, and strongly agree. There are five subscales in this scale: team structure (six questions), leadership (six questions), situation monitoring (six questions), mutual support (five questions), and communication (five questions). At least 28 and at most 140 points can be taken from TAQ. A high score in the scale indicates that the attitudes of nurses towards teamwork characteristics are positive. The Cronbach's alpha value of the original scale was between 0.70 and 0.89. In this study, the Cronbach's alpha value was found to be 0.95.

CBI-24 was developed by Wolf et al.[21] to assess nursing care. The scale was reorganized by Wu et al.[22] into four subscales consisting of assurance of human presence, professional knowledge and skill, respectful deference to others, and positive connectedness. The validity and reliability study of the Turkish version of the scale was carried out by Kurşun and Kanan.[23] CBI-24 consists of 24 items grouped under four subscales: assurance of human presence (8 items), professional knowledge and skill (5 items), respectful deference to others (6 items), and positive connectedness (5 items). CBI-24 has 6-point Likert-type items (1 = never, 2 = almost never, 3 = sometimes, 4 = generally, 5 = often, 6 = always). In the reliability study, the Cronbach's alpha value of the original scale was found to be 0.95. In this study, the Cronbach's alpha value was found to be 0.93.

Data analysis

Statistical Package of the Social Science (SPSS) version 16.0 program was used to carry out the statistical analysis of the data. Categorical measurements (such as gender, educational status, and clinic of employment) were calculated as counts and percentages, and numerical measurements as means, standard deviations, and frequencies. Correlations among the scales and their subscales were assessed using Spearman's correlation test. Statistical significance level was taken as P < 0.05 throughout the tests.


A total of 116 nurses, 18 (15.5%) males and 98 (84.5%) females, participated in the study, in which the effect of teamwork attitudes on caring behaviors was investigated. The average age of the nurses was 35.56 ± 7.9 years, 58% were university or higher education graduates, and 81.9% were married. Of the nurses, 40.5% had 1–10 years of working experience in the profession, while 84.5% had between 1 and 10 years of working experience in their units. A total of 86.2% worked between 40 and 49 hours per week and 57.8% worked in shifts. The average working hours per week was 44.5 ± 9.8. Of the nurses, 63.8% stated that they had been previously trained on teamwork [Table 1].

Table 1:
Distribution of descriptive characteristics of nurses (n=116)

The mean of CBI-24 total score of the nurses was 4.95±0.54, and the mean scores of the assurance of human presence, professional knowledge and skill, respectful deference to others, and positive connectedness subscales were 5.25 ± 0.63, 5.49 ±.54, 5.09±.67, and 4.84±.70, respectively. The total TAQ scores of the nurses ranged from 28 to 140, with a mean score of 112.11 ± 17.86. The scores of the team structure, leadership, situation monitoring, mutual support, and communication subscales were 23.95 ± 4.07, 25.41 ± 4.46, 24.60 ± 3.86, 17.62 ± 4.29, and 20.51 ± 3.74, respectively [Table 2].

Table 2:
CBI-24 and TAQ total and subscale mean scores of nurses

It was found that there were statistically positive correlations between CBI-24 and TAQ total scores and all subscale scores of the nurses (P < 0.05). The team structure, leadership, situation monitoring, mutual support, and communication subscale scores correlated statistically positively with the respectful deference to others and positive connectedness scores (P < 0.05). There was a statistically positive correlation between the mutual support and assurance of human presence mean scores (P < 0.05). Moreover, there were statistically significant positive correlations between the leadership, situation monitoring, and professional knowledge and skill subscales (P < 0.05). The team structure, leadership, situation monitoring, and communication subscales were not significantly correlated with the assurance of human presence scores (P > 0.05). The team structure, mutual support, and communication subscale scores were not significantly correlated with the professional knowledge and skill subscale scores (P > 0.05) [Table 3].

Table 3:
The relationship between TAQ and CBI-24 scores


Today, an effective teamwork is considered an important tool throughout the world to ensure patient-centered and quality nursing services.[6] This is because for a healthy human life, new ideas and processes are necessary in healthcare services.[24] To that end, it is important to identify the main components of the teamwork system and nursing care practices by means of research that can provide data on the team-based caring process.[6]

Caring for a person is seen as the essence and basis of the nursing profession. Knowledge, attitudes, and skills of nurses are important factors; they take roles in creating a basis of caring behaviors and in assessing the quality of care.[25] In their study, Yılmaz et al.[26] found the mean of CBI-24 total scores to be 5.59 ± 0.15. In their study, the mean scores of the subscales – assurance of human presence, professional knowledge and skill, respectful deference to others, and positive connectedness – were 5.50 ± 0.23, 5.83 ±.25, 5.56 ±.21, and 5.50 ±.34, respectively. In our study, the mean of CBI-24 total scores of the nurses was 4.95 ± 0.54, and the mean scores of the subscales – assurance of human presence, professional knowledge and skill, respectful deference to others, and positive connectedness – were 5.25±.63, 5.49 ±.54, 5.09 ±.67, and 4.84 ±.70, respectively [Table 2]. These results are important as they indicate that the nurses' perceptions of caring behaviors were at a good level, and with regard to caring behaviors, the nurses had tendencies to assess and enhance the quality of care to ensure a totalitarian care. Moreover, in our study, the most important caring behavior reported by the nurses was the professional knowledge and skill competence [Table 2]. As a matter of fact, it is stated in earlier studies in the literature that nurses regard clinical knowledge and skill accumulation as the most essential caring behavior.[2728]

Enhancing teamwork attitudes and perceptions is the first step to ensure safe and quality patient care.[6] The results of our study show that the nurses' mean scores of attitudes toward general teamwork and their mean scores of team structure, team leadership, situation monitoring, mutual support, and communication subscales were at a good level [Table 2]. The results of the study by Çelik and Karaca[2] (2017) on nurses' attitudes toward teamwork are similar to those of our study. Their study is important in that it has positively demonstrated nurses' attitudes toward effective teamwork, which is one of the indispensable criteria for quality care provided by nurses.

An effective teamwork is considered a critical element in terms of patient safety and quality of care. Caring is defined as a humane action, and this humane action can only be efficiently demonstrated and practiced as a team.[29] Teamwork is an indispensable component in delivering quality care.[330] Based on the results of our study, there was a positive correlation between general teamwork attitudes and caring behaviors of the nurses. It was found that the nurses had positive thoughts and attitudes toward the necessity of collaboration among team members to offer quality patient care [Table 3].

To offer quality patient care, the establishment of reassurance and professional connectedness among team members is linked to whether the intrateam communication properly transforms into an action.[31] In our study, the teamwork attitudes of the nurses were positively correlated with respectful deference to others and positive connectedness as well as mutual support and assurance of human presence [Table 3]. In a qualitative study conducted by Cruz et al.,[31] one of the participants stated with reference to mutual support among team members that respect is very important in teamwork, and that being part of a team depends entirely on respect. Another participant stated that there should be trust among team members, otherwise it would be impossible to work together. Therefore, the working atmosphere is essential for team members to be able to effectively sustain patient care in an institution. This environment should involve constructivism in human relations, flexibility and openness in ideas, and mutual trust and respect.[2] It is also imperative that healthcare professionals have the ability to work within a team spirit. Accordingly, it is recommended to improve knowledge and skills of nurses for working together, collaboration, and teamwork.[16]

Today, more attention has begun to be paid to different expertise and skills of team members, and it has been understood that to prevent undesired events, it is necessary to have an understanding of teamwork carried out in collaboration rather than in hierarchical relations in contemporary teams.[6] In this study, it was found that the nurses' knowledge and skill attitudes were positively correlated with leadership and situation monitoring (P < 0.05) [Table 3]. Many factors affecting the development of accidents and adverse events in patient care have been associated with a lack of teamwork rather than a lack of clinical skills.[16] Therefore, to sustain an optimum level of patient care, it is believed that team leaders should have the skills to support teamwork and to enable professional skills to be displayed.

Study limitations

Teamwork attitudes and behavioral assessments in the study were limited to the self-reports of the nurses in the surgical clinics of one state hospital only.


In conclusion, it was found that the nurses who participated in this study had a good level of teamwork attitudes and caring behaviors. There was a positive correlation between the teamwork attitudes and caring behaviors of the nurses. In line with these results, in-service training programs should be organized for the sustainment of patient care within the framework of team collaboration, and such trainings should regularly be repeated. Research studies on the subject should be continued, and observational behavioral assessments should be carried out.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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Attitude; caring behavior; nurse; surgical clinic; teamwork

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