BECAUSE NURSING work environments are complex, prioritizing work is essential and nursing workloads often need to be reprioritized on a shift-by-shift basis. Research suggests that the model of nursing care is critical in defining the nursing work environment.1 Organizational structures, leadership, autonomy, multidisciplinary collaboration, and interpersonal relationships influence nursing work environments and satisfaction.1
Challenges in clinical nursing are receiving more attention because they relate to nurse satisfaction and, ultimately, to patient satisfaction. Reimbursement changes mean that patients' perspectives on hospital care, as quantified by the Hospital Consumer Assessment of Healthcare Providers and Systems, carry a reimbursement weight of 30%.2 Healthcare leaders must develop and sustain environments that support patient safety and evidence-based care while restoring high levels of satisfaction in the workplace.
To redesign clinical care delivery to improve patient outcomes, The Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, recommends that nurses serve as key contributors.3 This article describes our evidence-based project to improve the delivery of care and patient and staff satisfaction with team nursing. Team nursing is defined as “a group of people who are mutually dependent on one another to achieve a common goal.”4 The primary benefit of this approach is that pairing nurses provides a resource and supplement to patient care.
Meet the unit
The Transitional Care Unit (TCU) is an 18-bed high-acuity, bedside telemetry, step-down unit with an open admission structure. The TCU cares for a diverse surgical and medical patient population. The surgical population includes patients with multisystem trauma, complex surgical issues, and kidney transplants. The medical population includes patients needing acute and chronic mechanical ventilator management, those experiencing hemodynamic and respiratory instability, those requiring sepsis management, and patients in acute alcohol withdrawal. The patient-to-nurse ratio was generally 2:1 or 3:1 before the implementation of team nursing, and this ratio was unchanged after the implementation of team nursing.
The concept of the team nursing model was first considered for implementation in the TCU due to turnover, an influx of new nurse hires, an increase in patient acuity, fluctuating staffing needs, and a decrease in both staff morale and satisfaction. The need to implement team nursing in the TCU was determined by staff feedback and a high recruit of novice nurses.
What's team nursing?
The team nursing model of care involves pairing nurses who work as a team to deliver patient care. This model utilizes the diversity of skills, education, and qualification level of the entire staff. Team members work collaboratively and share responsibility. Nurse satisfaction is increased when team nursing is used because nurses feel supported, the environment is collaborative, and staff communication improves. Research shows that team nursing can improve quality and patient safety.5
The concept of team nursing was developed in the 1950s in response to changes in nursing skill mix. According to Fernandez et al., numerous patient-care facilities that had adopted a team nursing model for patient care reported improved levels of communication and significant increases in job satisfaction and staff morale.6 Because our skill mix included novice nurses, the need for support and mentoring of less experienced RNs was identified. Research revealed team nursing provided an increased level of support for less experienced staff, improving their confidence in providing nursing care.6
The results of a baseline survey to evaluate staff satisfaction and morale indicated staff members were dissatisfied because of a lack of teamwork and support from peers in patient care. Believing that poor nurse satisfaction is related to undesirable patient outcomes and decreased quality of care, the authors of this article, who were the key stakeholders, decided that a team nursing model of care would be implemented. After the start of team nursing, patients received care from two nurses per shift rather than one. This also created continuous nursing coverage.
Planning for changing the unit practices included educating staff individually, in staff meeting presentations, and via electronic communication. All staff received instruction in pairing novice and seasoned nurses to care for a four- to six-patient assignment according to guidelines, responsibilities of the charge nurse and the paired team members, and modification of the patient handoff process.
On each shift, the charge nurse's responsibility was to pair nurses appropriately based on patient acuity and create balanced assignments. Teams conducted patient handoff together and collaborated throughout the shift to accomplish tasks and provide coverage when either member was off the unit.
The chief stakeholders conducted a brief trial of team nursing over a 24-hour period before rollout. No barriers were identified that would prevent a timely implementation. Team nursing in TCU was then launched for a trial period of 90 days. Ongoing evaluation included monthly staff surveys to elicit feedback and monitor the level of morale while identifying barriers.
The original goal of increasing staff satisfaction and continuity of care by 10% was surpassed. Results of the monthly staff surveys indicated an 88% compliance rate in participation in the team nursing approach. Preimplementation survey results indicated 61% of staff felt supported during their shift. In contrast, postimplementation survey results showed that 72% of staff felt supported, an 11% increase.
Preimplementation survey results also indicated 38% of staff felt they were held accountable by their peers; postimplementation survey results illustrated that 58% of staff felt they were held accountable. In addition, the staff's perception of continuity of care increased by over 45% throughout the course of the project.
After initiating team nursing, an incidental finding of zero falls over a 3-month period was noted. In contrast, five falls occurred in fiscal year 2015. TCU also achieved a Tier 1 rating on the Press Ganey employee engagement survey during the same period, the highest rating a nursing unit can achieve, reflecting an engaged, patient-centered culture.
Benefits of team nursing observed in the TCU included increased staff satisfaction rates, improved morale, and increased patient safety. With the initiation of team nursing, many encouraging examples of the positive effects team nursing can provide were observed.
For example, a novice nurse was paired with a highly regarded, experienced nurse. The team was assigned to a high-acuity, complex patient. The experienced nurse assisted the novice nurse when her expertise was sought and also when she observed the need for her assistance. After the shift was complete, the novice nurse was thankful to have been teamed with such a knowledgeable and experienced nurse. She stated she felt supported during her shift and took away prioritization and organization skills while enhancing her assessment and critical thinking skills.
The only complaints reported were prolonged patient handoff time and incidental overtime; both were resolved. The patient handoff routine reverted to being done individually rather than as a team, which eliminated incidental overtime. Consistent nursing coverage provided a heightened level of safety and support.
Team nursing a win
The TCU has experienced a culture change secondary to the implementation of team nursing. The charge nurse is now more readily available to assist on the unit rather than assigning meal times, covering patient assignments, or at times, transferring patients off the unit.
One lesson learned was that the model can easily be adapted to meet the needs of the nursing staff and patients, and unit demands. Based on feedback received from staff, team nursing was adapted to meet the needs of our unit and has become the standard of care. Team nursing is a universal model of care that can be easily assimilated into any nursing unit's routines.
1. King A, Long L, Lisy K. Effectiveness of team nursing compared with total patient care on staff wellbeing when organizing nursing work in acute care ward settings: a systematic review protocol. JBI Database Syst Rev Implement Rep
2. Centers for Medicare and Medicare Services. HCAHPS: Patients' perspectives of care survey. 2014. https://http://www.cms.gov
3. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health
. Washington, DC: The National Academies Press; 2011.
4. NSW Department of Health. Ways of Working in Nursing Resource Package
. North Sydney, Australia: Nursing and Midwifery Office; 2011. http://www.health.nsw.gov.au
5. Cioffi J, Ferguson L. Team nursing: experiences of nurse managers in acute care settings. Aust J Adv Nurs
6. Fernandez R, Johnson M, Tran DT, Miranda C. Models of care in nursing: a systematic review. Int J Evid Based Healthc