- Email: [email protected]
Neonatal Intensive Care Unit and Emergency Department Nurses' Descriptions of Working Together: Building Team Relationships to Improve Safety
Neonatal Intensive C a re U n i t a n d Emergency Department Nurses’ Descriptions of Wor ki ng Toget he r: B u i l d i n g Te a m Relationships to I m p ro v e S a f e t y Debora Simmons, RN, MSN, CCRN, CCNSa,b,c,*, Gwen Sherwood, PhD, RNd KEYWORDS Teamwork Safety Qualitative analysis Nurses’ perceptions
Teams and the work of teams are being scrutinized as key variables to improve patient care quality and safety. At its simplest, teams are defined as 2 or more individuals working toward a common goal or objective.1 In reality, delivery of health care is a high-risk team-critical activity requiring many skills that are still being defined.2 Creating strong team environments is a crucial challenge to health care organizations. The around-the-clock demands of the health care delivery structure and staffing issues create difficult conditions for developing strong teams. Although teamwork has been repeatedly cited as essential, the component skills that team members
Project support was obtained from the Agency for Healthcare Research and Quality (1PO1HS1154401). a College of Nursing, Texas Woman’s University, Houston, TX, USA b Rural and Community Health Institute, Texas A & M University, Bryan, TX, USA c The Patient Safety Education Project (PSEP), Buehler Center on Aging, Health & Society, Northwestern University, Chicago, IL, USA d University of North Carolina at Chapel Hill, School of Nursing, Carrington Hall CB, 7460, Chapel Hill, NC 27599, USA * Corresponding author. E-mail address: [email protected] Crit Care Nurs Clin N Am 22 (2010) 253–260 doi:10.1016/j.ccell.2010.03.007 0899-5885/10/$ – see front matter ª 2010 Published by Elsevier Inc.
ccnursing.theclinics.com
254
Simmons & Sherwood
need have not yet been thoroughly explored. We have little understanding of the effect of the individual’s ability to contribute to a team’s overall cohesiveness and capacity to agree on and achieve common goals. Creating high-functioning teams requires development of skills, knowledge, and traits.3 The purpose of this paper is to report the results of a secondary qualitative analysis of nurses’ perceptions of working together on high-performance teams in a neonatal intensive care unit (NICU) and on trauma resuscitation teams in the emergency department (ED). The study is part of a larger study4,5 of interdisciplinary teamwork from a patient safety perspective conducted by a team of researchers in a Center for Patient Safety. Exploration of the perceptions of teamwork internal to members may elucidate the skills, knowledge, and attitudes required for highly functioning teams that can assist in transforming education in health care professions. BACKGROUND
Effective teamwork is cited as the most important competency to improve quality and safety in health care. The Institute of Medicine6 reports that 70% of adverse events in health care settings are attributable to miscommunication and poor working relationships. Team performance is influenced by multiple environmental variables and human factors so that measurement is difficult. Economic pressures to trim costs complicate management of the inherent limitations of human performance. Providers have limited preparation in communication and care coordination across disciplines, a challenge in caring for complex patients who require multiple disciplines for their care. The complexity of care and the lack of systematic ways to share concerns and information contribute to an increasingly complex work environment for nurses creating a hazard to patient safety.7 Although teamwork is considered a critical factor in delivering high-quality, safe patient care, the intricacies of effective teamwork and communication are not fully understood.2 Many studies have looked at team dynamics and training in an effort to increase performance and understand lapses.8–12 Team composition is 1 of the domains used to explain team behaviors, influenced by unit environment, attitudes about hierarchy, and demographics such as age and education. Deep-level composition in teams examines variables on the individual level, including personality, values, and attitudes.13 Deep-level composition is not readily apparent when observing teams; however, deep-level composition may have greater influence on performance. Deep-level attributes of personality, attitudes, and values may be important not only to the team’s performance but also in forming new teams. STUDY DESIGN
The purpose of the study was to identify and describe nurses’ perceptions of working together across providers in the ED and the NICU. The research question was: What are nurses’s descriptions of working together in the NICU and on trauma resuscitation teams in the ED? Design
The study used a descriptive qualitative design.14 This secondary analysis is from a large project to help design safety initiatives by asking interprofessional health care providers about their perceptions of working together as a means of identifying and improving teamwork behaviors. The focus of this paper is to examine nurses’ descriptions of working together in high-performance areas including the ED and NICU. Data collection was in focus groups with open-ended questions to understand nurse
Building Team Relationships to Improve Safety
perspectives because there is little anecdotal evidence from nursing perspectives on team behaviors. Focus groups encourage simultaneous and systematic questioning among individuals to elicit valuable perspectives from group synergy and may provide broader and deeper descriptions. We applied qualitative research methods to analyze transcripts of the focus group interviews to develop themes for building a theoretic foundation or as the basis for future instrument development. Setting and Participants
The study was conducted in a 500-bed, urban, teaching hospital in an academic health center in south-central United States. Nurses from the NICU and the ED were chosen for this study because they are part of defined intensive interdisciplinary groups who care for patients and sometimes come together for specific events requiring prompt work in teams in unexpected circumstances with many of the interventions guided by protocols and seniority. Half of the focus groups were conducted with nurses who work in a busy Level I trauma center and participate in trauma resuscitation teams. The NICU had 80 beds. Each area is staffed with more than 50 registered nurses of varying seniority and education. Volunteer participants in each area were recruited using flyers placed in the work areas to attend scheduled focus groups led by 2 researchers. Eleven volunteer participants from NICU participated in 2 focus groups. All were female with an average age of 40 years and 14 years’ experience. Five of the 8 participants from the ED were female and 3 were male with an average age of 36 years and 11 years’ experience. There were 5 African Americans, 12 Caucasians, 1 Hispanic, and 1 Asian, which represented the demographics of the units. Data Collection
After human subjects review and approval, data were collected in 4 focus groups, 2 from each service area. After obtaining consent, participants completed the Demographic Form with information such as gender, education level, age, experience, and ethnicity. Each focus group met once in a hospital conference room before or after their shift. One researcher led the focus groups following the Interview Guide developed with open-ended questions to elicit descriptions of how providers work together in NICU and on trauma resuscitation teams in the ED, and the other took field notes. The term working together is a less specific phrase than teamwork, which allowed participants a broader range of responses. Interviews ranged in length from 70 minutes to 90 minutes, were recorded, transcribed verbatim, and checked for accuracy by a research assistant. The 2 researchers kept field notes during the interviews. Participants received a small stipend at the end of the interviews. One researcher led the focus groups using open-ended questions from the Interview Guide, Tell me your observations about how providers work together in your area. To gain richer descriptions, participants were asked to describe how people worked together to complete specific critical activities that have detailed protocols. NICU nurses were asked to describe a unit admission as well as when an infant required resuscitation. The ED nurses were asked to describe what happens when the trauma resuscitation team is called to the ED. Participants described their role and influences on how they completed their responsibilities. Nurses also described what happens when things go right and what happens when things go wrong, and described the effect on the safety of the patient. Qualitative Data Analysis
Two researchers, 1 who was involved in the interviews and 1 who was not, followed descriptive qualitative procedures. Each read and re-read the transcripts to understand
255
256
Simmons & Sherwood
the whole, highlighted relevant data bits, and then synthesized those into themes to be able to see the descriptive view. Through continuing reflection and analysis, each theme was defined by descriptive phrases or quotes to give clarity and meaning. The 2 researchers compared and contrasted data elements with the established themes to verify the fit for inclusion. Themes were pooled for all groups for re-analysis to gain a composite description of how nurses work with providers in these 2 service areas. RESULTS
Three themes emerged from the nurses’ descriptions of working together: personal and professional attributes, developing and maintaining relationships, and concurrence. Direct quotes and descriptors further define and illustrate each theme. Theme 1: Personal and Professional Attributes
Personal and professional attributes recognized the differences of each provider and the need to respect differences in educational preparation, expertise, personalities, backgrounds, and personal preferences for how work was completed. In spite of differences, nurses described a shared goal and work ethic, mutual respect, and helping/learning from each other. All providers shared the goal ‘‘working together for the patient’s sake’’ by forsaking individual interests when patients’ lives were at stake; care of the patient superseded personal differences. With strong personalities, prior reputations, and hierarchical systems, nurses described ‘‘individualism, egoism, and attitudism’’ as having a strong effect on working together. These attitudes could emanate from staff nurses, the charge nurse, attending physicians, residents, and other workers. One nurse described putting aside personal differences as ‘‘We have to do it, because I’m as accountable for my patient as my charge nurse.’’ Focusing on caring for the patient, providers described mutuality in helping each other, or if you did not help, then you were not likely to get help when you needed it yourself. One nurse described assisting each other in times of crisis and heavy work load, saying, ‘‘now, if you’re the kind of person who’s gonna stop for a second and walk into that room when they’re doing CPR, they’re getting that stroke patient, and help them out, then they’re gonna do the same for you.’’ When providers helped cover each other, there were checks and balances that ensured care was completed. Respecting each other as equals and learning from each other was described as having a positive influence on work. Conflict often resulted when respect was lacking, especially when new residents lacked appreciation for nurses’ seniority and expertise. Recognizing a sense, order, and understanding of each other’s roles and hierarchy contributed to feelings of respect that supported the value of each team member. One nurse summarized the implications of mutual respect as ‘‘’I’m the doctor, and you’re the nurse.’ Here, you don’t have that kind of an attitude or you’re not going to work well with people.’’ Respect built trust that was essential to work in the intense environments of health care. Theme 2: Developing and Maintaining Relationships
Relationships are built on trust and respect and take time, skill, and repeated contact to develop and maintain. Time was a recurrent theme when describing close team relationships. A strong relationship emerged after working together over time and in intense circumstances. Nurses expressed the importance of the need to develop trust and rapport between team members for learning and understanding each other’s abilities and communication styles. This contributed to a sense of trust between team members that enhanced communication. Simply stated by 1 nurse ‘‘the more you
Building Team Relationships to Improve Safety
work together the more you know each other.’’ Another nurse stated: ‘‘Twelve hours with 1 person is a long time. You get to know people.’’ In addition, shared traumatic experiences magnified the feeling of closeness. As a result, nurses felt they experienced enhanced relationships that opened communication. One described it as ‘‘especially these people right here, I can pretty much say just about anything to them, almost all the time, and we all understand exactly what we’re saying.’’ Integrating new members into the team was an important aspect of developing and maintaining relationships. Nurses described coaching new members of the team, physicians included, in how the unit functioned to ensure procedures were followed. Communication was a critical descriptive element for how people worked together and how effectively work was completed. Poor communication that contributed to stress in the unit could affect future interactions if not dealt with immediately or in the aftermath of the event. Nurses felt conflict resolution was a significant part of maintaining relationships and tried to help coworkers know ways to ask questions as well as apologize and express appreciation appropriately and with timeliness. They helped coach conversations between members after stressful events to help clear the air to build relationships and enable learning from each other and from events for always improving care. Unresolved conflict remained a barrier to communication, which 1 nurse described as ‘‘I just decided to walk away from the problem and then ever since it has been a barrier between the person and myself.’’ One nurse described the challenge of working with a new attending physician, ‘‘You’re gonna trust us today to try and do some of these things for you’’ and later feeling a positive outcome ‘‘when he came down and said, ‘If I don’t say it, I really appreciate all the stuff you guys do down here’.’’ The units with a cohesive staff found it disruptive to move to another area and try to learn new protocols. Communication, community, and relationships can be disrupted by changing units or shifts. Although units may have patients who were similar, the teams were highly segregated even to the unit clerk level. This did not affect their respect of the other unit or shift but was described as ‘‘different culturally, different atmosphere.’’ Theme 3: Concurrence Among Members
A concurrence of thought between team members was the third theme and included a shared understanding of roles, abilities, and responsibilities as well as of rationales behind orders, a ‘‘getting on the same page to get the job done.’’ In each of the units, protocols such as cardiac or trauma resuscitation specified provider roles and responsibilities, but it was sometimes chaotic in the beginning of a resuscitation event as roles and responsibilities often shifted depending on who responded. Nurses were often the ones who helped fill in gaps and felt a responsibility to help get everyone working together. Nurses described feelings of frustration and uncertainty when team leadership was unclear with role confusion. Often leadership went to the stronger personality on the team. When the role was not clear it was described as stressful to adjust to each person’s style. One nurse described the benefit of having role clarity as ‘‘. people know what they need to do; it’s an experienced team that understands, and also respects the kind of bad injuries there can be. And there’s just a rapport between them.’’ Without concurrence of roles and rationales work can become confusing and stressful ‘‘It gets confusing because differing providers have different ideas about how things, processes should be done.’’ Even so, communication was easier in situations where the team had a shared history, ‘‘we know each other, how each other works so well we don’t even have to talk, sometimes.’’
257
258
Simmons & Sherwood
IMPLICATIONS
Nurses’ descriptions of working together reveal the need for clear roles and responsibilities, knowing what each discipline can contribute in the stress of a care intervention is a critical factor in positive outcomes. Getting to know each other over time can help build respect and trust from shared experiences. The 3 themes demonstrate the multifaceted sphere of team behaviors as a composite connection between stressful behaviors mitigated by meaningful associations derived from respect, communication, and knowing each other’s work styles and skills. The complexity of the relationships also illustrate why it is so difficult to measure the outcomes of teamwork and to establish the essential content of team training. The results of this study support the call from the Institute of Medicine that all health care professionals must have opportunities to learn strategies to support interdisciplinary teamwork as well as the organizational support to make it possible.7,15 The data illustrate how the complex environment in which nurses work requires skills for intranursing teamwork and interprofessional teamwork to coordinate care across multiple disciplines16 and achieve the concurrence of a shared mental model. The myriad of contextual factors that contribute to poor teamwork raises the possibility of adverse events. Hierarchical sharing of information, frequent interruptions, multitasking, and work overload are part of the environmental hazards of nurses’ work that contribute to poor teamwork and work dissatisfaction, high burnout, and turnover. High-quality organizations strive to create work environments that support teamwork behaviors among all team members and promote satisfaction17,18 derived from the type of collaborative relationships described in this study. Recognizing that effective communication is influenced by the situation or personalities involved, implementing standardized communication can help convey timely critical information needed to assure quality care.19 Skilled team members have a well-developed self-awareness20 to be able to function alternately as leader, member, and follower, depending on needs of the patient and family, competence of the health care provider, and situational context, contributing to safe, effective, and satisfying patient care. Questions remain how to best develop these critical skills. High-reliability industries such as commercial aviation have shown that frequent training with other providers with implementation of standardized tools can improve teamwork.21 This concern for the lack of evidence-based team training curricula was the impetus for development of a national project, Quality and Safety Education for Nurses.22 An expert, interdisciplinary panel used an iterative method to achieve consensus among nurse educators to define teamwork for nursing and interprofessional teams as fostering open communication, mutual respect, and shared decision making to achieve quality patient care, further clarified by measureable objectives for knowledge (cognitive), attitudes (affective), and performance (skills). TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) is another effort to increase teamwork behavior through training, deployed nationally in many hospitals by the Agency for Healthcare Quality and Research.23 TeamSTEPPS is based on 4 key skills: Leadership, Situation Monitoring, Mutual Support, and Communication. Organizationally, TeamSTEPPS seeks a system change in which providers gain specific skills that support team performance principles including behavioral methods, human factors, and cultural change, many of the same contextual factors identified in this study of nurses’ perceptions of working together. However, questions remain on the most effective curriculum to develop safer health care teams.
Building Team Relationships to Improve Safety
SUMMARY
Effective communication is essential for teams to successfully coordinate care and achieve quality patient outcomes.24 Traditional health profession education remains a professional silo experience for most, with limited opportunities for students to participate in team training across professions, whether in simulation or guided clinical learning, to be prepared to navigate complex work settings and coordinate care.25 Health care is indeed a team sport involving multiple individuals to deliver safe care. The systems of health care require coordination of multiple teams to provide the full range of care needed, presenting an educational challenge for all health professionals. ACKNOWLEDGMENTS
The authors gratefully acknowledge the leadership and guidance of Eric Thomas, MD, MPH. REFERENCES
1. Baker DP, Salas E. In: Brannick MT, Salas E, Prince C, editors. Team performance assessment and measurement: theory, methods, and applications. New Jersey: Lawrence Erlbaum; 1997. p. 331–55. 2. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004;13(Suppl 1):i85–90. 3. Salas E, Wilson KA, Murphy CE, et al. Communicating, coordinating, and cooperating when lives depend on it: tips for teamwork. Jt Comm J Qual Patient Saf 2008;34(6):333–41. 4. Thomas E, Sherwood G, Mulhollem J, et al. Working together in the neonatal intensive care unit: provider perspectives. J Perinatol 2004;24:552–9. 5. Thomas EJ, Taggart B, Crandell S, et al. Teaching teamwork during the neonatal resuscitation program: a randomized trial. J Perinatol 2007;27(7):409–14. 6. Greiner AC, Knebel E. Health professions education. A bridge to quality. Washington, DC: National Academies Press; 2003. 7. Page A. Keeping patients safe: transforming the work environment of nurses. Washington, DC: National Academies Press; 2004. 8. Upenieks VV, Lee EA, Flanagan ME, et al. Healthcare team vitality instrument (HTVI): developing a tool assessing healthcare team functioning. J Adv Nurs 2009;66(1):168–76. 9. Amos MA, Hu J, Herrick CA. The impact of team building on communication and job satisfaction of nursing staff. J Nurses Staff Dev 2005;21(1):10–6. 10. Kaissi A, Johnson T, Kirschbaum MS. Measuring teamwork and patient safety attitudes of high-risk areas. Nurs Econ 2003;21(5):211–8, 207. 11. Chakraborti C, Boonyasai RT, Wright SM, et al. A systematic review of teamwork training interventions in medical student and resident education. J Gen Intern Med 2008;23(6):846–53. 12. Mickan SM, Rodger SA. Effective health care teams: a model of six characteristics developed from shared perceptions. J Interprof Care 2005;19(4):358–70. 13. Bell ST. Deep-level composition variables as predictors of team performance: a meta-analysis. J Appl Psychol 2007;92(3):595–615. 14. Morse J. Emerging from the data: the cognitive process of analysis in qualitative inquiry. In: Morse J, editor. Critical issues in qualitative research methods. Newbury Park (CA): Sage; 1994. p. 23–43.
259
260
Simmons & Sherwood
15. Ladden MD, Bednash G, Stevens DP, et al. Educating interprofessional learners for quality, safety and systems improvement. J Interprof Care 2006;20:497–505. 16. Apker J, Propp KM, Ford WSZ, et al. Collaboration, credibility, compassion, and coordination: professional nurse communication skill sets in health care team interactions. J Prof Nurs 2006;22(3):180–9. 17. Ulrich B, Woods D, Hart K, et al. Critical care nurses’ work environments value of excellence in Beacon units and Magnet organizations. Crit Care Nurse 2007;27: 68–77. 18. Thomas E, Sherwood G, Helmreich R. Lessons from aviation: teamwork to improve patient safety. Nurs Econ 2003;21(5):241–3. 19. Dayton E, Henriksen K. Communication failure: basic components, contributing factors, and the call for structure. Jt Comm J Qual Patient Saf 2007;33(1):34–47. 20. Horton-Deutsch S, Sherwood G. Reflection: an educational strategy to develop emotionally competent nurse leaders. J Nurs Manag 2008;16:946–54. 21. Sherwood G, Thomas E, Simmons D, et al. A teamwork model to promote patient safety in critical care. Crit Care Nurs Clin North Am 2002;14:333–40. 22. Cronenwett L, Sherwood G, Barnsteiner J, et al. Quality and safety education for nurses. Nurs Outlook 2007;55(3):122–31. 23. Agency for Healthcare Research and Quality. TeamSTEPPS: national implementation. Available at: http://teamstepps.ahrq.gov/index.htm. 2009. Accessed November, 2009. 24. Haig K, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Qual Saf Health Care 2006;32:167–75. 25. Barnsteiner J, Disch J, Hall L, et al. Promoting interprofessional education. Nurs Outlook 2007;55(3):144–53.
Teams and the work of teams are being scrutinized as key variables to improve patient care quality and safety. At its simplest, teams are defined as 2 or more individuals working toward a common goal or objective.1 In reality, delivery of health care is a high-risk team-critical activity requiring many skills that are still being defined.2 Creating strong team environments is a crucial challenge to health care organizations. The around-the-clock demands of the health care delivery structure and staffing issues create difficult conditions for developing strong teams. Although teamwork has been repeatedly cited as essential, the component skills that team members
Project support was obtained from the Agency for Healthcare Research and Quality (1PO1HS1154401). a College of Nursing, Texas Woman’s University, Houston, TX, USA b Rural and Community Health Institute, Texas A & M University, Bryan, TX, USA c The Patient Safety Education Project (PSEP), Buehler Center on Aging, Health & Society, Northwestern University, Chicago, IL, USA d University of North Carolina at Chapel Hill, School of Nursing, Carrington Hall CB, 7460, Chapel Hill, NC 27599, USA * Corresponding author. E-mail address: [email protected] Crit Care Nurs Clin N Am 22 (2010) 253–260 doi:10.1016/j.ccell.2010.03.007 0899-5885/10/$ – see front matter ª 2010 Published by Elsevier Inc.
ccnursing.theclinics.com
254
Simmons & Sherwood
need have not yet been thoroughly explored. We have little understanding of the effect of the individual’s ability to contribute to a team’s overall cohesiveness and capacity to agree on and achieve common goals. Creating high-functioning teams requires development of skills, knowledge, and traits.3 The purpose of this paper is to report the results of a secondary qualitative analysis of nurses’ perceptions of working together on high-performance teams in a neonatal intensive care unit (NICU) and on trauma resuscitation teams in the emergency department (ED). The study is part of a larger study4,5 of interdisciplinary teamwork from a patient safety perspective conducted by a team of researchers in a Center for Patient Safety. Exploration of the perceptions of teamwork internal to members may elucidate the skills, knowledge, and attitudes required for highly functioning teams that can assist in transforming education in health care professions. BACKGROUND
Effective teamwork is cited as the most important competency to improve quality and safety in health care. The Institute of Medicine6 reports that 70% of adverse events in health care settings are attributable to miscommunication and poor working relationships. Team performance is influenced by multiple environmental variables and human factors so that measurement is difficult. Economic pressures to trim costs complicate management of the inherent limitations of human performance. Providers have limited preparation in communication and care coordination across disciplines, a challenge in caring for complex patients who require multiple disciplines for their care. The complexity of care and the lack of systematic ways to share concerns and information contribute to an increasingly complex work environment for nurses creating a hazard to patient safety.7 Although teamwork is considered a critical factor in delivering high-quality, safe patient care, the intricacies of effective teamwork and communication are not fully understood.2 Many studies have looked at team dynamics and training in an effort to increase performance and understand lapses.8–12 Team composition is 1 of the domains used to explain team behaviors, influenced by unit environment, attitudes about hierarchy, and demographics such as age and education. Deep-level composition in teams examines variables on the individual level, including personality, values, and attitudes.13 Deep-level composition is not readily apparent when observing teams; however, deep-level composition may have greater influence on performance. Deep-level attributes of personality, attitudes, and values may be important not only to the team’s performance but also in forming new teams. STUDY DESIGN
The purpose of the study was to identify and describe nurses’ perceptions of working together across providers in the ED and the NICU. The research question was: What are nurses’s descriptions of working together in the NICU and on trauma resuscitation teams in the ED? Design
The study used a descriptive qualitative design.14 This secondary analysis is from a large project to help design safety initiatives by asking interprofessional health care providers about their perceptions of working together as a means of identifying and improving teamwork behaviors. The focus of this paper is to examine nurses’ descriptions of working together in high-performance areas including the ED and NICU. Data collection was in focus groups with open-ended questions to understand nurse
Building Team Relationships to Improve Safety
perspectives because there is little anecdotal evidence from nursing perspectives on team behaviors. Focus groups encourage simultaneous and systematic questioning among individuals to elicit valuable perspectives from group synergy and may provide broader and deeper descriptions. We applied qualitative research methods to analyze transcripts of the focus group interviews to develop themes for building a theoretic foundation or as the basis for future instrument development. Setting and Participants
The study was conducted in a 500-bed, urban, teaching hospital in an academic health center in south-central United States. Nurses from the NICU and the ED were chosen for this study because they are part of defined intensive interdisciplinary groups who care for patients and sometimes come together for specific events requiring prompt work in teams in unexpected circumstances with many of the interventions guided by protocols and seniority. Half of the focus groups were conducted with nurses who work in a busy Level I trauma center and participate in trauma resuscitation teams. The NICU had 80 beds. Each area is staffed with more than 50 registered nurses of varying seniority and education. Volunteer participants in each area were recruited using flyers placed in the work areas to attend scheduled focus groups led by 2 researchers. Eleven volunteer participants from NICU participated in 2 focus groups. All were female with an average age of 40 years and 14 years’ experience. Five of the 8 participants from the ED were female and 3 were male with an average age of 36 years and 11 years’ experience. There were 5 African Americans, 12 Caucasians, 1 Hispanic, and 1 Asian, which represented the demographics of the units. Data Collection
After human subjects review and approval, data were collected in 4 focus groups, 2 from each service area. After obtaining consent, participants completed the Demographic Form with information such as gender, education level, age, experience, and ethnicity. Each focus group met once in a hospital conference room before or after their shift. One researcher led the focus groups following the Interview Guide developed with open-ended questions to elicit descriptions of how providers work together in NICU and on trauma resuscitation teams in the ED, and the other took field notes. The term working together is a less specific phrase than teamwork, which allowed participants a broader range of responses. Interviews ranged in length from 70 minutes to 90 minutes, were recorded, transcribed verbatim, and checked for accuracy by a research assistant. The 2 researchers kept field notes during the interviews. Participants received a small stipend at the end of the interviews. One researcher led the focus groups using open-ended questions from the Interview Guide, Tell me your observations about how providers work together in your area. To gain richer descriptions, participants were asked to describe how people worked together to complete specific critical activities that have detailed protocols. NICU nurses were asked to describe a unit admission as well as when an infant required resuscitation. The ED nurses were asked to describe what happens when the trauma resuscitation team is called to the ED. Participants described their role and influences on how they completed their responsibilities. Nurses also described what happens when things go right and what happens when things go wrong, and described the effect on the safety of the patient. Qualitative Data Analysis
Two researchers, 1 who was involved in the interviews and 1 who was not, followed descriptive qualitative procedures. Each read and re-read the transcripts to understand
255
256
Simmons & Sherwood
the whole, highlighted relevant data bits, and then synthesized those into themes to be able to see the descriptive view. Through continuing reflection and analysis, each theme was defined by descriptive phrases or quotes to give clarity and meaning. The 2 researchers compared and contrasted data elements with the established themes to verify the fit for inclusion. Themes were pooled for all groups for re-analysis to gain a composite description of how nurses work with providers in these 2 service areas. RESULTS
Three themes emerged from the nurses’ descriptions of working together: personal and professional attributes, developing and maintaining relationships, and concurrence. Direct quotes and descriptors further define and illustrate each theme. Theme 1: Personal and Professional Attributes
Personal and professional attributes recognized the differences of each provider and the need to respect differences in educational preparation, expertise, personalities, backgrounds, and personal preferences for how work was completed. In spite of differences, nurses described a shared goal and work ethic, mutual respect, and helping/learning from each other. All providers shared the goal ‘‘working together for the patient’s sake’’ by forsaking individual interests when patients’ lives were at stake; care of the patient superseded personal differences. With strong personalities, prior reputations, and hierarchical systems, nurses described ‘‘individualism, egoism, and attitudism’’ as having a strong effect on working together. These attitudes could emanate from staff nurses, the charge nurse, attending physicians, residents, and other workers. One nurse described putting aside personal differences as ‘‘We have to do it, because I’m as accountable for my patient as my charge nurse.’’ Focusing on caring for the patient, providers described mutuality in helping each other, or if you did not help, then you were not likely to get help when you needed it yourself. One nurse described assisting each other in times of crisis and heavy work load, saying, ‘‘now, if you’re the kind of person who’s gonna stop for a second and walk into that room when they’re doing CPR, they’re getting that stroke patient, and help them out, then they’re gonna do the same for you.’’ When providers helped cover each other, there were checks and balances that ensured care was completed. Respecting each other as equals and learning from each other was described as having a positive influence on work. Conflict often resulted when respect was lacking, especially when new residents lacked appreciation for nurses’ seniority and expertise. Recognizing a sense, order, and understanding of each other’s roles and hierarchy contributed to feelings of respect that supported the value of each team member. One nurse summarized the implications of mutual respect as ‘‘’I’m the doctor, and you’re the nurse.’ Here, you don’t have that kind of an attitude or you’re not going to work well with people.’’ Respect built trust that was essential to work in the intense environments of health care. Theme 2: Developing and Maintaining Relationships
Relationships are built on trust and respect and take time, skill, and repeated contact to develop and maintain. Time was a recurrent theme when describing close team relationships. A strong relationship emerged after working together over time and in intense circumstances. Nurses expressed the importance of the need to develop trust and rapport between team members for learning and understanding each other’s abilities and communication styles. This contributed to a sense of trust between team members that enhanced communication. Simply stated by 1 nurse ‘‘the more you
Building Team Relationships to Improve Safety
work together the more you know each other.’’ Another nurse stated: ‘‘Twelve hours with 1 person is a long time. You get to know people.’’ In addition, shared traumatic experiences magnified the feeling of closeness. As a result, nurses felt they experienced enhanced relationships that opened communication. One described it as ‘‘especially these people right here, I can pretty much say just about anything to them, almost all the time, and we all understand exactly what we’re saying.’’ Integrating new members into the team was an important aspect of developing and maintaining relationships. Nurses described coaching new members of the team, physicians included, in how the unit functioned to ensure procedures were followed. Communication was a critical descriptive element for how people worked together and how effectively work was completed. Poor communication that contributed to stress in the unit could affect future interactions if not dealt with immediately or in the aftermath of the event. Nurses felt conflict resolution was a significant part of maintaining relationships and tried to help coworkers know ways to ask questions as well as apologize and express appreciation appropriately and with timeliness. They helped coach conversations between members after stressful events to help clear the air to build relationships and enable learning from each other and from events for always improving care. Unresolved conflict remained a barrier to communication, which 1 nurse described as ‘‘I just decided to walk away from the problem and then ever since it has been a barrier between the person and myself.’’ One nurse described the challenge of working with a new attending physician, ‘‘You’re gonna trust us today to try and do some of these things for you’’ and later feeling a positive outcome ‘‘when he came down and said, ‘If I don’t say it, I really appreciate all the stuff you guys do down here’.’’ The units with a cohesive staff found it disruptive to move to another area and try to learn new protocols. Communication, community, and relationships can be disrupted by changing units or shifts. Although units may have patients who were similar, the teams were highly segregated even to the unit clerk level. This did not affect their respect of the other unit or shift but was described as ‘‘different culturally, different atmosphere.’’ Theme 3: Concurrence Among Members
A concurrence of thought between team members was the third theme and included a shared understanding of roles, abilities, and responsibilities as well as of rationales behind orders, a ‘‘getting on the same page to get the job done.’’ In each of the units, protocols such as cardiac or trauma resuscitation specified provider roles and responsibilities, but it was sometimes chaotic in the beginning of a resuscitation event as roles and responsibilities often shifted depending on who responded. Nurses were often the ones who helped fill in gaps and felt a responsibility to help get everyone working together. Nurses described feelings of frustration and uncertainty when team leadership was unclear with role confusion. Often leadership went to the stronger personality on the team. When the role was not clear it was described as stressful to adjust to each person’s style. One nurse described the benefit of having role clarity as ‘‘. people know what they need to do; it’s an experienced team that understands, and also respects the kind of bad injuries there can be. And there’s just a rapport between them.’’ Without concurrence of roles and rationales work can become confusing and stressful ‘‘It gets confusing because differing providers have different ideas about how things, processes should be done.’’ Even so, communication was easier in situations where the team had a shared history, ‘‘we know each other, how each other works so well we don’t even have to talk, sometimes.’’
257
258
Simmons & Sherwood
IMPLICATIONS
Nurses’ descriptions of working together reveal the need for clear roles and responsibilities, knowing what each discipline can contribute in the stress of a care intervention is a critical factor in positive outcomes. Getting to know each other over time can help build respect and trust from shared experiences. The 3 themes demonstrate the multifaceted sphere of team behaviors as a composite connection between stressful behaviors mitigated by meaningful associations derived from respect, communication, and knowing each other’s work styles and skills. The complexity of the relationships also illustrate why it is so difficult to measure the outcomes of teamwork and to establish the essential content of team training. The results of this study support the call from the Institute of Medicine that all health care professionals must have opportunities to learn strategies to support interdisciplinary teamwork as well as the organizational support to make it possible.7,15 The data illustrate how the complex environment in which nurses work requires skills for intranursing teamwork and interprofessional teamwork to coordinate care across multiple disciplines16 and achieve the concurrence of a shared mental model. The myriad of contextual factors that contribute to poor teamwork raises the possibility of adverse events. Hierarchical sharing of information, frequent interruptions, multitasking, and work overload are part of the environmental hazards of nurses’ work that contribute to poor teamwork and work dissatisfaction, high burnout, and turnover. High-quality organizations strive to create work environments that support teamwork behaviors among all team members and promote satisfaction17,18 derived from the type of collaborative relationships described in this study. Recognizing that effective communication is influenced by the situation or personalities involved, implementing standardized communication can help convey timely critical information needed to assure quality care.19 Skilled team members have a well-developed self-awareness20 to be able to function alternately as leader, member, and follower, depending on needs of the patient and family, competence of the health care provider, and situational context, contributing to safe, effective, and satisfying patient care. Questions remain how to best develop these critical skills. High-reliability industries such as commercial aviation have shown that frequent training with other providers with implementation of standardized tools can improve teamwork.21 This concern for the lack of evidence-based team training curricula was the impetus for development of a national project, Quality and Safety Education for Nurses.22 An expert, interdisciplinary panel used an iterative method to achieve consensus among nurse educators to define teamwork for nursing and interprofessional teams as fostering open communication, mutual respect, and shared decision making to achieve quality patient care, further clarified by measureable objectives for knowledge (cognitive), attitudes (affective), and performance (skills). TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) is another effort to increase teamwork behavior through training, deployed nationally in many hospitals by the Agency for Healthcare Quality and Research.23 TeamSTEPPS is based on 4 key skills: Leadership, Situation Monitoring, Mutual Support, and Communication. Organizationally, TeamSTEPPS seeks a system change in which providers gain specific skills that support team performance principles including behavioral methods, human factors, and cultural change, many of the same contextual factors identified in this study of nurses’ perceptions of working together. However, questions remain on the most effective curriculum to develop safer health care teams.
Building Team Relationships to Improve Safety
SUMMARY
Effective communication is essential for teams to successfully coordinate care and achieve quality patient outcomes.24 Traditional health profession education remains a professional silo experience for most, with limited opportunities for students to participate in team training across professions, whether in simulation or guided clinical learning, to be prepared to navigate complex work settings and coordinate care.25 Health care is indeed a team sport involving multiple individuals to deliver safe care. The systems of health care require coordination of multiple teams to provide the full range of care needed, presenting an educational challenge for all health professionals. ACKNOWLEDGMENTS
The authors gratefully acknowledge the leadership and guidance of Eric Thomas, MD, MPH. REFERENCES
1. Baker DP, Salas E. In: Brannick MT, Salas E, Prince C, editors. Team performance assessment and measurement: theory, methods, and applications. New Jersey: Lawrence Erlbaum; 1997. p. 331–55. 2. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004;13(Suppl 1):i85–90. 3. Salas E, Wilson KA, Murphy CE, et al. Communicating, coordinating, and cooperating when lives depend on it: tips for teamwork. Jt Comm J Qual Patient Saf 2008;34(6):333–41. 4. Thomas E, Sherwood G, Mulhollem J, et al. Working together in the neonatal intensive care unit: provider perspectives. J Perinatol 2004;24:552–9. 5. Thomas EJ, Taggart B, Crandell S, et al. Teaching teamwork during the neonatal resuscitation program: a randomized trial. J Perinatol 2007;27(7):409–14. 6. Greiner AC, Knebel E. Health professions education. A bridge to quality. Washington, DC: National Academies Press; 2003. 7. Page A. Keeping patients safe: transforming the work environment of nurses. Washington, DC: National Academies Press; 2004. 8. Upenieks VV, Lee EA, Flanagan ME, et al. Healthcare team vitality instrument (HTVI): developing a tool assessing healthcare team functioning. J Adv Nurs 2009;66(1):168–76. 9. Amos MA, Hu J, Herrick CA. The impact of team building on communication and job satisfaction of nursing staff. J Nurses Staff Dev 2005;21(1):10–6. 10. Kaissi A, Johnson T, Kirschbaum MS. Measuring teamwork and patient safety attitudes of high-risk areas. Nurs Econ 2003;21(5):211–8, 207. 11. Chakraborti C, Boonyasai RT, Wright SM, et al. A systematic review of teamwork training interventions in medical student and resident education. J Gen Intern Med 2008;23(6):846–53. 12. Mickan SM, Rodger SA. Effective health care teams: a model of six characteristics developed from shared perceptions. J Interprof Care 2005;19(4):358–70. 13. Bell ST. Deep-level composition variables as predictors of team performance: a meta-analysis. J Appl Psychol 2007;92(3):595–615. 14. Morse J. Emerging from the data: the cognitive process of analysis in qualitative inquiry. In: Morse J, editor. Critical issues in qualitative research methods. Newbury Park (CA): Sage; 1994. p. 23–43.
259
260
Simmons & Sherwood
15. Ladden MD, Bednash G, Stevens DP, et al. Educating interprofessional learners for quality, safety and systems improvement. J Interprof Care 2006;20:497–505. 16. Apker J, Propp KM, Ford WSZ, et al. Collaboration, credibility, compassion, and coordination: professional nurse communication skill sets in health care team interactions. J Prof Nurs 2006;22(3):180–9. 17. Ulrich B, Woods D, Hart K, et al. Critical care nurses’ work environments value of excellence in Beacon units and Magnet organizations. Crit Care Nurse 2007;27: 68–77. 18. Thomas E, Sherwood G, Helmreich R. Lessons from aviation: teamwork to improve patient safety. Nurs Econ 2003;21(5):241–3. 19. Dayton E, Henriksen K. Communication failure: basic components, contributing factors, and the call for structure. Jt Comm J Qual Patient Saf 2007;33(1):34–47. 20. Horton-Deutsch S, Sherwood G. Reflection: an educational strategy to develop emotionally competent nurse leaders. J Nurs Manag 2008;16:946–54. 21. Sherwood G, Thomas E, Simmons D, et al. A teamwork model to promote patient safety in critical care. Crit Care Nurs Clin North Am 2002;14:333–40. 22. Cronenwett L, Sherwood G, Barnsteiner J, et al. Quality and safety education for nurses. Nurs Outlook 2007;55(3):122–31. 23. Agency for Healthcare Research and Quality. TeamSTEPPS: national implementation. Available at: http://teamstepps.ahrq.gov/index.htm. 2009. Accessed November, 2009. 24. Haig K, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Qual Saf Health Care 2006;32:167–75. 25. Barnsteiner J, Disch J, Hall L, et al. Promoting interprofessional education. Nurs Outlook 2007;55(3):144–53.