Teamwork can be defined as how individuals work with other members of the group to complete tasks.1 In nursing, working as an effective team leads to more productive and efficient care with improved patient outcomes.2 Research demonstrates that with effective teamwork there are fewer patient falls with injury and decreased mortality.3 Units with effective teams show higher job satisfaction and less turnover.4 Although it's recognized that education alone can't change behaviors, teamwork can be improved with teamwork training.2,5
Nurses at a university hospital noted opportunities for improvement in the RN-to-RN interaction domain of the National Database of Nursing Quality Indicators® (NDNQI®) RN survey in 2017. These nurses, including two faculty members, the director of nursing professional practice and innovation, nurse managers, and a clinical nurse specialist (CNS), formed a committee to undertake a project that aligned with the unit's action plans to improve nursing satisfaction with the work environment in collaboration with the university's College of Nursing.
The project committee chose Kalisch's teamwork model to evaluate an education intervention predicted to help staff members become a high-performing team.5 The teamwork model consists of five elements: team leadership, collective orientation, mutual performance monitoring, backup behavior, and adaptability. These core behaviors are coordinated using three mechanisms: shared mental models, closed loop communication, and mutual trust.6 The educational component of the teamwork model consists of selecting volunteers from each unit to attend a 2-day training session. These trainers then educate all nursing staff members on their unit during three 1-hour sessions using a train-the-trainer approach.6
The project was presented to administrators who approved the use of Kalisch's program content, but not the educational component. Members of the project committee would be the facilitators instead of unit nurses. In addition, instead of three 1-hour sessions, a condensed 1-hour session would be offered to educate the nursing staff. The aim of the project was to measure if the educational session impacted teamwork on nursing units in a university hospital.
After reviewing the NDNQI results, the five units with the lowest employee satisfaction scores were selected for participation. The project committee contacted the five nurse managers of the units and all were supportive. The project also received Institutional Review Board approval.
The preintervention Nursing Teamwork Survey (NTS), a validated and reliable 33-question tool using a 5-point Likert type scale, was sent via a secure web application for building and managing online surveys and databases to all RNs, LPNs, medical office assistants (MOAs), healthcare technicians (HCTs), and other members of the selected units to obtain baseline data. The NTS, along with demographic questions, was sent to 167 participants, with 128 responses for a 77% response rate.
Instead of trainers from the unit, educational sessions were facilitated by one faculty member, two CNSs, a nursing director, an assistant manager, a clinical practice nurse consultant, and a nurse scientist. Facilitators participated in a training session led by a project committee member before the educational intervention to ensure consistency. The educational sessions, consisting of a discussion about baseline results specific to the individual unit's unique areas of concern and strategies to improve and sustain teamwork, were held during all three shifts over a 2-week period.
Nurse managers were encouraged to participate by ensuring staff members attended one of the educational sessions, even though it wasn't mandatory, and implementing teamwork strategies on the units. However, nurse manager follow-up varied, which affected the participation of the entire unit.
Upon completion of the educational session, postintervention surveys were sent to 196 staff members from participating units, with 78 responses for a 40% response rate. The number of post-intervention surveys sent was larger than the number of preintervention surveys; although new staff members didn't participate in the intervention, it was felt they could respond to questions about unit teamwork.
Statistical software was used to compare pre- and postintervention demographics (see Table 1) and pre- and postintervention changes in perceived teamwork. There were no statistically significant differences in any of the 33 surveyed items, including the overall ratings. Although the overall total didn't show significant results, each unit was broken down for further analysis to determine if there was an increase in teamwork after the educational session. (See Figure 1.) All but Unit B showed small improvements in the overall rating of teamwork postintervention.
Turnover was taken into consideration on all units and an additional question was added to the postintervention survey asking participants to select if they attended the education session. Unit A had 58% of respondents attend the education session; Unit B, 78%; Unit C, 42%; Unit D, 44%; and Unit E, 83%. The two units with the lowest attendance percentage (Unit C and Unit D) also had the highest increase in overall teamwork ratings pre- to postintervention. Unit B, with a 78% attendance rate, showed a decline in the overall teamwork rating and Unit E (83% attendance) had the lowest increase in overall teamwork rating. To better understand this, the 33 questions were broken down into a five-factor analysis for all units. (See Figure 2.)
Unit A (58% attendance) showed slight variations in pre- to postintervention results, Unit B (78% attendance) declined in all five factors, Unit E (83% attendance) had increases in all factors except the shared mental model with a 0.08 decline, and Unit C (42% attendance) and Unit D (44% attendance) increased in all five factors.
Participants were asked how long they've worked on the unit in their current role. This question was filtered by unit and showed that Unit A and Unit B both had an increase (12.3%, 9.96%) in the percentage of staff members who've been on the unit for 2 years or longer, along with a decrease in the leadership factor. The other three units (C, D, and E) all had a decrease (15.5%, 38.4%, and 6.6%) in the number of staff members who've been on the unit for 2 years or longer and an increase in all five factors, with the exception that Unit E had a small decrease in the shared mental model factor. Both Units C and D had the lowest percentages of staff on the unit for 2 years or longer, which correlate with the lower percentages of those attending the educational session, possibly due to high staff turnover. The results suggest that other factors may have impacted the increase in perceived teamwork.
The 1-hour educational session didn't statistically improve nursing teamwork scores. However, staff members reported that they did make changes in their practice after the intervention. Thirty percent of staff members intentionally focused on teamwork daily by using more team terminology. Thirty-five percent of staff members expanded the use of the buddy system through more proactive back-up behaviors. Twenty-seven percent of staff members began their huddles by stating the team goal. Forty-three percent of staff members increased praise, gratitude, and recognition of teamwork. Twenty-four percent of staff members increased the use of team member strengths during surges. And 32% of staff members increased the use of direct, prompt, and respectful communication to resolve conflict openly.
In addition to the changes reported by staff, the educational session also allowed for discussion of teamwork in a learning environment that encouraged open dialogue. Participants often used the sessions as an opportunity to discuss how to better manage conflict. Facilitators described strategies for staff members to manage conflict themselves instead of asking the nurse manager to solve the problem. A key aspect of the educational session was discussing each person's role on the team and seeing the perspectives of all members. Despite healthy discussions, staff turnover was perceived to be a barrier to maintaining change. However, nurse managers reported that the staff members who contributed the most to conflict within the team no longer worked on the unit at the time of the postintervention survey. Future research should evaluate how teamwork interventions may result in individuals who don't value teamwork leaving the team by their own choice or through disciplinary action.
Finally, the methodology used in this project had benefits and limitations. The use of Kalish's NTS was a feasible way to measure the perception of teamwork on units before and after the educational intervention. Although the tool is limited by measuring perception, nurse managers agreed that improving perception is valuable because perception is often appreciated as reality by the team. The feasibility of the NTS was enhanced by using a web-based application rather than a paper-and-pencil version.
Despite the benefits, unit-based encouragement to participate in the pre- and postintervention surveys was low due to competing priorities and lack of a sustainment strategy to keep the team engaged in the project. Lack of sustainment strategies also contributed to the smaller percentage of staff members reporting implementation of recommended changes to optimize teamwork. The intervention didn't require formal or informal leaders on the unit to play a prescribed role in sustainment. A lack of clear expectations and engagement of all unit leaders limited the long-term sustainment of change.
Several valuable lessons were learned during this project. Education was delivered in a 1-hour session in a room provided on the clinical unit. Some nurses had a difficult time focusing during the session because they were temporarily relieved from their patient assignment knowing that once the hour concluded they would return to the assignment.
Another lesson learned was that further details should've been provided to the nurse managers on each unit regarding their role in postintervention sustainment. Each nurse manager was asked to identify one change they would implement on their unit based on the educational session, but not all followed through. Providing more support for managers would've allowed them more time to focus on sustaining changes in team behaviors.
The last lesson learned is the importance of maintaining the project timeline. Several events led to the delay of the postintervention survey. One reason for the delay was that the project team was sensitive to the fact that staff members on the units were being asked to participate in many hospital-wide satisfaction surveys. To minimize survey fatigue, it was decided to delay the postintervention survey. This could've impacted the results if there was a high level of nurse turnover.
Best possible care
The project committee was impressed with staff members' level of dedication to their work and teams. Each nurse who participated in the educational session expressed a strong desire to foster teamwork to improve patient outcomes. At the heart of each nurse is the desire to provide the best possible patient care, and a high-performing team is an optimal way to accomplish this.
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