The importance of quality teamwork in healthcare has been the subject of a number of studies in healthcare. Teamwork has been associated with a higher level of job staff satisfaction,1-6 a higher quality of care,4,7-13 an increase in patient safety,5,14-19 greater patient satisfaction with their care,11,20 more productivity,21 and a decreased stress level.22,23 Highly functioning teams have also been shown to offer a wider range of support to inexperienced staff.22
Outside healthcare, there have been a plethora of studies highlighting the value of teamwork. For example, one investigation of flight crews demonstrated the link between teamwork and safety. These researchers evaluated the impact of fatigue on error rate and found that staff who had flown together for several days made fewer errors than teams who were rested and had not worked together for very long. The fatigued team actually made more errors, but because the team had worked together, they were able to compensate and catch one another's near misses. This is due to less stress, knowledge of the vulnerabilities and strengths of other team members, and the practice of monitoring performance and giving feedback to one another.22
Many studies have tested interventions to improve teamwork. Approaches which have been found to enhance teamwork include cross training,24,25 teamwork skills training,26 Crew Resource Training,14,27-31 role playing,32 simulation,33,34 automation,35 posttraining feedback,36 team-building activities,37,38 and a combination of training and action groups.39
Specifically within healthcare, there has been a growing awareness of the need to improve teamwork. The Joint Commission on the Accreditation of Hospitals (JCAHO) in July 2004 released a Sentinel Event Alert on the prevention of infant deaths. Its database showed that nearly three-quarters of hospitals cited communication breakdown and teamwork problems as a major reason for these deaths. The JCAHO recommended that hospitals conduct formal team training to the obstetrical/perinatal team.40 In a study conducted by Dynamics Research Corporation, weaknesses and error patterns in emergency department teamwork were assessed, and a prospective evaluation of a formal teamwork training intervention was conducted. Improvements were obtained in 5 key teamwork measures, and most importantly, clinical errors were significantly reduced.41 Hope et al42 found that a team-building initiative for health profession students resulted in an improved interdisciplinary understanding, team atmosphere, and teamwork skills. In another study, teamwork training of emergency department physicians and nurses significantly increased the quality of team behaviors, attitudes toward teamwork, and decreased clinical errors.16
Only a few studies have tested methods of increasing nursing teamwork. Amos et al43 found that the introduction of team-building activities resulted in greater staff communication, stronger interpersonal relationships, and greater job satisfaction. Britton44 reported that a team development program conducted for hospital nurse managers led to greater understanding and clarity of work roles and improved cohesion and teamwork at the management level. In another study, a team-building intervention showed an improvement in group cohesion, nurse satisfaction, and turnover rates.45
This article reports the results of a study which will add to the body of knowledge about nursing teamwork. It evaluates the impact of an intervention designed to enhance teamwork and promote staff engagement. The staff engagement component was considered an essential element of the intervention in that teamwork could not be achieved without the involvement and commitment of the staff. The aim of this project was to determine the impact of an intervention designed to enhance teamwork and staff engagement on the rate of patient falls, patient satisfaction, the staff's assessment of level of teamwork on their unit, and vacancy and turnover rates.
The study was conducted on a 41-bed medical-oncology unit in a community hospital in 2004/2005. There were 55 staff members on the unit-32 registered nurses (RN), 2 licensed practical nurses, 15 certified nurse assistants (CNAs), and 6 unit secretaries.
Measures for this project were patient fall rates, patient satisfaction scores, staff assessment of level of teamwork, staff vacancy, and turnover rates.
Patient falls per 1,000 patient days were collected before (January 2000-August 2004) and after (September 2004-June 2005) the teamwork and engagement intervention.
Patient satisfaction was measured with the Professional Research Consultants Patient Satisfaction Survey Tool, which has been utilized in hospitals throughout the United States for 20 years.46 Scoring is based on a point scale with weighting factors: Excellent (100), Very Good (80), Good (60), Fair (40), and Poor (20). In terms of validity of the instrument, Professional Research Consultants reports that they have performed various tests of internal validity. The Cronbach [alpha] was .936 (n = 824) for the data from the medical unit utilized in this investigation. Professional Research Consultants also reports that they have conducted "side-by-side studies to compare various methodologies" and that by "utilizing norm data, they have demonstrated stability and consistency across various groups."46
Staff ratings of level of teamwork were completed 6 months after the intervention implementation. Confidential interviews were conducted with 48 of 55 of the unit's staff by an external data collector who had no previous contact with the organization. The interviews were a combination of structured questions (eg, "Has teamwork improved, stayed the same, or gotten worse?") and semistructured, open-ended questions (eg, "How do you assess the RN and CNA relationships at this time compared to before the project? Give specific examples").
Staff turnover, exclusive of relocation, return to school, retirement, or death, was calculated by dividing the preventable turnover FTEs by the budgeted FTEs for full-time and part-time RNs, licensed practical nurses, and CNA employees minus the open positions for the period before (March-August 2004) and after the intervention (March-August 2005). Staff vacancy rates were calculated by determining the average of the vacant positions each pay period divided by the budgeted positions. This was collected for the 6 months before and 6 months after the teamwork and engagement project.
Description of the Intervention
The teamwork and engagement enhancement intervention tested in this study was based on principles of teamwork,11,14,16,19,30 change management,47 training,32-34,36,39,42 and staff engagement.47 The steps in the intervention can be seen in Figure 1.
|Figure 1. Staff teamwork and engagement enhancement intervention.|
In the first step, 11 focus groups were conducted with RNs (5 groups), licensed practical nurses (1 group), CNAs (4 groups), and unit secretaries (2 groups) to determine their perceptions of the level of teamwork on the unit and issues that inhibit and enhance teamwork. A total of 56 staff were interviewed, a participation rate of 97% of the unit staff. The purpose of the focus groups was to assess the level and nature of teamwork on the unit as well as the staff educational needs in the area of teamwork. Focus groups and interviews were also conducted with key stakeholders. Two focus groups with former unit patients were selected randomly from a list of discharged patients from the unit for a month prior to the implementation of the intervention. In addition, individual interviews were conducted with the 6 physicians who admitted the most patients to the unit. All of the focus groups and interviews were transcribed and analyzed using the N-Vivo qualitative research software. Major themes were identified.
These focus group data were compiled into a report which was presented in several feedback sessions, making it possible for each staff member on the unit to attend. The purpose of this second step in the process was not only to give the staff a report of the results of the focus groups they participated in but to also create a need for change. According to Kotter,47 the first step in any change process is to create a sense of urgency. He notes that "we underestimate the enormity of the task [of change], especially the first step, establishing a sense of urgency."47(p35) It is not uncommon for teams to deny that they have problems working together effectively even when they are obvious. Kotter47(p36) points out: "people will find a thousand ingenious ways to withhold cooperation from a process" they do not buy into. Focus group data, using quotations from staff members themselves, their patients, and the physicians they work with, were designed to be compelling and mitigate tendencies of staff to discount reality. These data were referred to repeatedly during the project.
After each presentation, staff members were asked if they were interested in working on a project to improve teamwork. As noted above, it is crucial in a change process to overcome complacency in order to gain the cooperation of those involved. Each group of staff indicated that they were committed to improving teamwork and supporting a project designed to improve it.
Values, Vision, and Goals
The next step was to conduct values, vision, and goals sessions, involving all unit staff in the process. Values (enduring beliefs which determine behavior) and vision (a compelling, inspirational, achievable, and comprehensible picture of the unit at some point in the future) gave direction to the unit staff and allowed the team to share in the development of a common unified direction.48 Once the values and vision were finalized, the entire staff engaged in a gap analysis. They looked at where they were now and compared it to their vision statement or where they wanted to be. They then identified the goals for the project or the first priorities they felt they should work on to achieve their vision.
Each staff member then attended a day-long team training program. As mentioned above, the focus groups served as the needs analysis for the teamwork-training requirements of the staff and also as a source of scenarios used in the role playing aspects of the training program. This information was used to specify the objectives, content, and posttraining evaluation of the program. Major deficiencies in teamwork knowledge, skills, and abilities-namely, feedback, conflict management, listening, and understanding of team information processing styles-were evident and formed the focus for the teamwork training.
Two guiding teams (which were soon combined into one due to confusion over overlapping efforts) were created to address the specified project goals of improving staff relationships (with an emphasis on the relationship between nurses and CNAs) and redesigning the work to facilitate teamwork and improve quality of care. Following Kotter's guidelines, guiding team membership included managers (with position power), representatives from the different job categories so that all viewpoints would be represented, credible staff with good reputations on the unit so that their ideas would be taken seriously by other employees, and staff with leadership capabilities.47(p57) In addition, staff with different information processing styles were selected to balance the talents of the group.49
The guiding team initiated their work with several intense day and half-day meetings, which focused on creative idea generation and the classification of ideas into a 4-cell diagram in which easy- to hard-to-implement was on one axis and high and low cost on the other axis.50 The idea was to assist the staff in selecting the easy-to-implement, low-cost ideas first so that early successes, or what Kotter refers to as "short term wins," could be achieved.47 A major change like this one takes a considerable amount of time. Yet, unit staff members look for convincing evidence that the work of the guiding team is paying off. By addressing the easy/low-cost items first, the guiding team met the needs of the staff, thus making it easier for the guiding team to take the time necessary to work on the more complex issues.
Rapid Testing and Implementation
Rapid testing of ideas was the next step. For example, ideas, such as redesign of the patient change-of-shift report, were tested on one of 3 of the unit's wings before being adapted unit-wide. A similar approach was used when the team decided to move all staff to 12-hour shifts from a mix of 8- and 12-hour shifts to decrease the number of handoffs between staff members and the number of different people they worked with.51 Implementation of permanent changes occurred when the testing of ideas proved successful. Maintenance of the changes was monitored on an ongoing basis by the guiding team.
Communication was a vital component of the project. The guiding teams adopted the assumption that they needed to communicate their messages in at least 4 ways before they could expect that staff members actually would hear and understand the messages. Kotter47(p94) notes that "effective information transferal almost always relies on repetition." Each guiding team member was assigned to 5 to 6 of the unit staff members (constituents) who were not on the team, and was responsible for keeping these staff members informed of the work of the team and gaining feedback from them. At the end of each meeting, a decision was made about what would be reported to the constituent staff members about the meeting, as well as what areas of feedback from the staff were needed for the next meeting. This communication occurred within 24 hours of the end of each guiding team meeting. A second method of communication involved the development of a special bulletin board in the staff lounge devoted to keeping everyone informed about the work of the project. The third method was an e-mail sent by the nurse manager to all staff members at the end of each meeting, and the fourth communication tool was a report about the project in each monthly unit staff meeting.
The ninth element of the project involved a systematic reinforcement by managers and guiding team members on the knowledge, skills, and attitudes taught in the training programs. This step was considered essential because training is a learning process and not a one-time event. Like any skill, teamwork competencies will decay without periodic reinforcement and practice. Thus, the awareness training (which focused on knowledge and attitudes) was followed by skills practice and recurrent skills maintenance.26
As can be seen in Figure 2, the 2-sample t test showed that the patient fall rates dropped significantly from a mean of 7.73 per 1,000 patient days before the team intervention to 2.99 after the intervention (t = 3.98, P < .001).
|Figure 2. Mean fall rates before and after intervention. |
Comparisons of the "excellent" scores on the Professional Research Consultants Patient Satisfaction Survey Tool for the study unit for quarters before and after the intervention approached but did not reach statistical significance. Patients' perceptions of nurses' promptness in responding to calls increased from 32.0% to 49.0%; nurses' communication with patients and family increased from 36.7% to 48.0%; and overall quality of nursing care increased from 46.0% to 52.0%.
Staff Ratings of Level of Teamwork
The staff ratings of level of teamwork were completed in July 2005, and showed that staff felt that teamwork had improved ([chi]2 = 36.065, P = .000). Figure 3 contains a graphic distribution of the responses to the question "Has teamwork improved, stayed the same, or gotten worse since the teamwork intervention?" When analyzed by shift, 84% of the nurses and 80% of the CNAs on days and 35% of the nurses and 60% of the CNAs on nights reported that teamwork had improved on the unit. The discrepancy between shifts was reported to be due to the fact that the night shift felt that their level of teamwork was higher than the day shift before the project was initiated. Figure 4 shows more changes that staff felt had helped to improve teamwork.
|Figure 3. Staff perception of changes in teamwork after the intervention. |
|Figure 4. Staff perception of changes that improved teamwork. RN indicates registered nurse, CNA, certified nursing assistant.|
Staff Turnover and Vacancy Rates
As can be seen in Figure 5, 2-sample t test showed that there was a significant drop in staff turnover rates after the intervention from 13.14 to 8.05 (t = 2.18, P = .033). Similarly, the vacancy rates declined significantly from before to after the teamwork enhancement project from 6.14 to 5.23 (t = 4.55, P = .0000).
|Figure 5. Turnover and vacancy rate before and after intervention. Turnover |
The major limitation of this study centered on the measurement of patient satisfaction. Not only were the number of patients surveyed small but the tool is proprietary and the data were collected by the company rather than by the researchers. In future studies, patient satisfaction should be measured directly by the researchers to ensure accuracy in data collection and analysis. This study needs to be replicated with other nursing teams and in other settings. Exploration of additional measures of teamwork and patient outcomes needs to be developed.
This study tests a specific intervention for improving nursing staff teamwork and engagement on a hospital medical unit. The intervention was based on established principles of change, training, teamwork, and empowerment. It involved extensive up front efforts to establish a sense of urgency among a large proportion of the unit staff undergoing the change. The intervention included involvement of the entire unit staff in the development of values, vision, and goals to guide the project; a teamwork training needs assessment; training in teamwork knowledge, skills, and attitudes customized to the unit; the appointment of a guiding team made up of unit staff and managers who engaged in creative idea generation, testing, and implementation of ideas for change; a comprehensive communication strategy to keep the entire unit staff informed and involved in the project; and follow-up after training by managers and guiding team members to reinforce the new behaviors and ultimately change the culture of the unit to one that supports and expects teamwork.
The team enhancement and engagement intervention followed a specific protocol developed before the initiation of the project but still allowed for flexibility within it to meet the specific needs of the participants. For example, unit staff made the decisions as to what specific changes they wished to make on their unit to foster teamwork.
The outcomes of this study are promising in that there was a significantly lower patient fall rate, lower turnover and vacancy rates, as well as staff self-reports of improved teamwork. Patient satisfaction improved but did not reach statistical significance, perhaps because the number surveyed was small.
Although this intervention was relatively extensive in scope, the potential to increase the quality of nursing care, avoid errors, decrease staff turnover, lower staff vacancy rates, and increase productivity makes the time and effort expended in this intervention worthy of the effort. Potential cost savings, although not measured in this study, would appear to be substantial (eg, decreased staff turnover, less errors, decreased length of stay, etc).
The results of the staff interviews, as well as ongoing observations of work behavior, demonstrate a continual need to work with staff in the areas of listening, feedback, and conflict management. The team is currently working on dividing themselves into smaller units in an effort to reduce the number of different individuals they are working with so that they can develop the culture necessary to function as a high performing team and to be able to monitor one another's performance, give feedback, conduct closed loop communication, put the team above the individual, and provide the team leadership needed.
The authors acknowledge the contributions of the study unit staff and managers and Suzanne Begeny, MS, RN, for conducting and analyzing the staff interviews.