GROUP

J Nurs Manag. 2018;1–8. wileyonlinelibrary.com/journal/jonm  |  1© 2018 John Wiley & Sons Ltd

Accepted: 1 October 2017

DOI: 10.1111/jonm.12582

O R I G I N A L A R T I C L E

Nursing teamwork in a health system: A multisite study

Jennifer A. Kaiser PhD, MSN, RN, CNE, Senior Nurse Researcher1  | Judith B. Westers MSN, BSN, RN, Director of Pediatric Services2

1Spectrum Health, Grand Rapids, MI, USA 2Helen DeVos Children’s Hospital, Grand Rapids, MI, USA

Correspondence Jennifer Kaiser, Spectrum Health, Grand Rapids, MI, USA. Email: [email protected]

Funding information This research did not receive any specific grant from funding agencies in the public, commercial, or not- for- profit sectors.

Aim: The aim of this study was to examine how the facets of teamwork exist among nurse- only teams in acute and continuing care settings. Background: The health care ‘team’ conventionally describes the interdisciplinary team in both literature and practice. Nursing- specific teams are rarely considered in the literature. An examination of this specific professional cohort is important to under- stand how teamwork exists among those who provide the majority of patient care. Method: This was a descriptive, comparative, cross- sectional study using the Nursing Teamwork Survey to measure teamwork of nursing- based teams among 1414 partici- pants in multiple acute care environments across a large Midwestern health system. Results: The characteristics of nursing teams were analysed. The results from the sub- scales within the teamwork model showed that nursing teams had a good understand- ing of the various roles and responsibilities. However, nurse team members held a more individualistic rather than collective team- oriented mindset. Conclusions and Implications for Nursing Management: Increased teamwork has a positive effect on job satisfaction, staffing efficiencies, retention and care delivery. Nurse leaders can use the information provided in this study to target the aspects of highly functioning teams by improving team orientation, trust and backup behaviours.

K E Y W O R D S

nursing, team, teamwork

1  | AIM

The aim of this study was to examine how the facets of teamwork exist among nurse- only teams in acute and continuing care settings. The facets of nursing teams were explored using a similar conceptual framework to those widely examined in the literature. The principal objective was to determine how acute care nursing teams align with the standards of highly effective teams in other professional domains. Additional questions to be answered included:

(1) What is the average level of nursing teamwork based on the characteristics used to describe highly effective teams?

(2) Are there differences in average total teamwork among various care settings (service lines)?

(3) Does one or more of the aspects of effective teamwork have a stronger prevalence in acute and continuing care settings?

(4) Are there differences in the average total teamwork based on edu- cation, gender, experience or work characteristics?

(5) Does teamwork correlate to job satisfaction, satisfaction with staff- ing and intent to leave the position?

2  | BACKGROUND

In the landmark reports To Err is Human, Crossing the Quality Chasm and The Future of Nursing, the Institute of Medicine clearly identi- fied the importance of team processes to high- quality health care.

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Like safety culture and systems thinking, the benefits of teamwork have been demonstrated in multiple industries including aviation, nuclear medicine and the military (Baker, Day, & Salas, 2006; Salas, Cook, & Rosen, 2008). These industries are considered ‘high reli- ability organisations’, defined as organisations that operate with low levels of safety events despite a complex hazardous environ- ment (Agency for Healthcare Research and Quality, 2006). A con- ceptual framework for highly effective teams has been established in high- reliability organisations (HROs) and adopted into the health care domain (Baker et al., 2006; Brady, Battles, & Ricciardi, 2015; Gaston, Short, Ralyea, & Casterline, 2016; Jain, Thompson, Chaudry, McKenzie, & Schwartz, 2008).

The common framework and interventions for teamwork thereby originate from non- health care organisations. The Agency for Healthcare Research and Quality (AHRQ) studied the processes of teamwork in high reliability organisations and created TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), a curriculum designed to improve teamwork skills and com- munication among health care professionals (Agency for Healthcare Research and Quality, 2006). TeamSTEPPS has been implemented in areas most comparable to its prototype, namely emergency depart- ments, surgical services, intensive care units and in situations such as cardiac arrest (Jones, Podila, & Powers, 2013; McCulloch et al., 2017). ‘Teams’ among the predominant health care literature are primarily in- terdisciplinary and largely situational or episodic as in surgery or emer- gency situations (Gaston et al., 2016; Jones et al., 2013; McCulloch et al., 2017).

To date there is little known research that provides a comprehen- sive analysis of teamwork specific to the health care industry with its own variants in practice, nor does the research on teamwork within health care extend much beyond its original settings of surgical, criti- cal and emergency care (Alexanian, Kitto, Rak, & Reeves, 2015; Baker et al., 2006; Kalisch, Lee, & Salas, 2010). The vast majority of studies of teamwork in health care are interprofessional (Alexanian et al., 2015; Baker et al., 2006; Korner, Wirtz, Bengel, & Goritz, 2015). ‘Although a large proportion of health care is delivered by nursing work teams in acute care hospitals, there has been very little research about team- work in this setting’ (Kalisch et al., 2010, p.42).

There are some key differences in the structure of nursing teams versus the multidisciplinary health care team. Kalisch defines nursing teams as the staff members – registered nurses, licensed practical nurses, nursing support staff – who work together on a given patient care unit. This nursing team provides the care and related administra- tive tasks for a group of patients (Kalisch et al., 2010). A primary differ- ence is that most professionals other than nurses spend time both on and off the unit in their normal workflow. A specific time set aside for collaboration, such as interdisciplinary rounds, is one of the few times in which all the team members are physically located in the same space and interacting face- to- face. Nursing teams continually work together for extended periods of time and workflow among team members directly overlaps.

Additionally, the ‘leader’ position of the interdisciplinary teams described in the literature has been held primarily by medical providers

(Alexanian et al., 2015; Baker et al., 2006; Korner et al., 2015). This history fails to consider nursing leadership in the team structure. Numerous researchers have identified that leader–member relation- ships directly affect the quality of team cohesion and effectiveness (Brunetto, Shriberg, Farr- Wharton, Shacklock, & Newman, 2013). An examination of teamwork with a nurse as the team leader may show significant differences from previous studies and present a critical fac- tor in teamwork.

The Nursing Teamwork Survey (NTS) was developed by Dr B. Kalisch in response to a lack of a teamwork measurement tool specific to health care with sound psychometric properties that could be used in a variety of patient care settings (Kalisch et al., 2010). The NTS has a reliability coefficient ranging from 0.77 to 0.87, and an internal consis- tency alpha coefficient of 0.94. Additional factor analysis showed item loading consistent with Salas’ Big Five framework (Kalisch et al., 2010). A unique aspect of the Nursing Teamwork Survey is that it is designed to focus specifically on nursing teams as opposed to interdisciplinary healthcare teams.

The conceptual model for this tool is Eduardo Salas’ ‘Big Five’ framework of teamwork. Salas’ framework was selected as the basis for the Nursing Teamwork Survey ‘because it is based on team- work behaviours and offers a practical explanation of the dynamics of teamwork’ (Kalisch et al., 2010; p. 43). The model upon which the NTS is based has similar subscales and origins of the widely used TeamSTEPPS® model developed by the Agency for Healthcare Research and Quality (AHRQ), with five subscales congruent to those in the NTS (Agency for Healthcare Research and Quality, 2006).

The ‘Big Five’ framework describes the knowledge, skills and atti- tudes required for effective teamwork. Simply put, the model describes the components of highly effective teams. True teamwork is defined as more than parallel work and collaboration. As Salas describes, highly effective teams consistently exhibit the following knowledge, skills and attitudes:

• have a clear and common purpose • compensate for each other • regularly provide feedback to each other and the team • self-correct • anticipate each other’s actions and needs • reallocate functions • adjust their strategy under stress • coordinate without the need to communicate • value the team goals over individual goals, and • strongly believe in the team’s collective ability to succeed (Baker

et al., 2006).

Extensive research suggests that teamwork is defined by this stan- dard set of inter- related knowledge, skills and attitudes that facilitate coordinated, adaptive performance (Baker et al., 2006). There are few studies that have determined whether these standard knowledge, skills and attitudes exist in nursing- specific teams.

Effective teamwork is a valuable aspect of patient care delivery. Research has confirmed that the ability of health care to become a

     |  3KAISER And WESTERS

high- reliability organisation (HRO) is dependent on its members to effectively and efficiently coordinate their activities. Teamwork has been found to increase the productivity of nursing work, enhance job satisfaction and promote optimum quality of care. Teamwork has also been linked to decreasing nurse stress, protecting patient safety and promoting greater patient satisfaction (Kalisch & Lee, 2009). It is logical that an understanding of the structure and func- tion of nursing teams is crucial in leveraging teams to realize these outcomes.

3  | METHOD

This was a descriptive, cross- sectional study using the Nursing Teamwork Survey to measure the teamwork of nursing teams in multiple acute care environments across a large Midwestern health system. Institutional IRB review #2014- 054 was obtained prior to implementation.

The Nursing Teamwork Survey (NTS) was used to measure team- work within the nursing work environment. The tool has demon- strated validity, reliability and acceptability in previous studies (Kalisch et al., 2010). This survey tool is unique in that the team members are specific to nursing, and includes staff nurses (registered nurses and licensed practical nurses), nursing assistants, nurse managers, charge nurses and unit secretaries.

The June 2015 survey involved the participation of 74 units/ areas within 11 hospitals in the health system. Hospitals included two large 1100 bed metropolitan health centres, a 190- bed multi- specialty children’s hospital, and eight rural or suburban smaller re- gional hospitals. Nursing units included were medical/surgical units ranging from 22 to 48 beds; an acute rehabilitation unit of 20 beds; rehabilitation continuing care services; a long- term acute care unit of 25 beds; critical care units including neurosurgical critical care, cardiac critical care, surgical critical care, and a 108 bed neonatal intensive care unit; 24 bed paediatric units, and 24 bed obstetric units in the urban and regional hospitals. Surgical services, emer- gency services and more episodic teams such as interventional areas were excluded from the sample. The study included any par- ticipant who held the role of registered nurse, licensed practical nurse, nursing assistant or technician, unit secretary, clinical nurse specialist, nursing supervisor, nurse manager or nurse educator within the designated nursing areas of practice. The purpose of this broad sample was to capture a variety of nursing teams and prac- tice settings.

A convenience sample of 1,414 nursing staff employees partici- pated, constituting a 33% return rate. Probability sampling techniques were not utilized and the response rate was low. However, a sample size of 1,414 provides a ±2.6% sampling error. The ratio of sample size to the number of survey items was 26:1, exceeding the minimum recommended ratios (Osborne & Costello, 2004).

Staff nurses comprised 55% of the sample, with 53% registered nurses. Twenty- three percent were nursing assistants, 4% were unit clerks, and the remainder were nurse leaders (charge nurse, nurse

manager, supervisor, director, educator or clinical nurse specialist). The majority (86.85%) of participants was female and the highest educa- tion level of most of the participants was a bachelor degree (54.67%). A small number of participants were new to their role (6%) or new to the unit (11%) defined as less than 6 months. Interestingly, 25% of the sample respondents were not licensed nurses, although com- parison by role indicated that most of these individuals were nursing assistants. Seventy- nine percent of participants worked full- time. Fifty- three percent of participants reported working the day shift (0700–1900) and 34% worked night shift (1900–0700). Forty- eight percent did not work any overtime in the last 3 months, 87% missed one shift or fewer in the last 3 months, and 74% had no intention of leaving their position.

The survey asks the demographic items of educational level, gender, age and job title. Work- related items include work shift and years of experience. Satisfaction items relate to current position and role, staffing adequacy and level of teamwork on the unit. Thirty- three items measuring descriptors of teamwork are divided into five subscales based on Salas’ ‘Big Five’ framework of teamwork. The subscales are defined as:

• Shared mental model: All team members understand their role and responsibilities and thus respectively work together to achieve a quality work outcome.

• Team leadership: Charge nurses or managers adequately monitor, distribute and balance the workload of the nurses.

• Backup: Team members willingly aid and help one another when they recognize someone is busy or overloaded with work.

• Trust: Team members trust each other enough to communicate ideas and information and value, seek and give each other construc- tive feedback.

• Team orientation: The team works together to improve each other’s weaknesses efficiently and effectively (Kalisch et al., 2010).

The survey was deployed to approximately 4200 nursing staff within 11 hospitals and facilities in the health system via a secure email link. Surveys needed to be completed in entirety for inclusion in the study. Voluntary completion indicated consent.

4  | RESULTS

4.1 | Average level of nursing teamwork

The total teamwork system average was M = 3.614 (SD = 0.441) on a 0–5 Likert scale. There is no benchmark score for this num- ber. Compared with previous studies using the Nursing Teamwork Survey, the health system used in this study appeared to be aligned with other hospitals (Kalisch, Labelle, & Boqin, 2013; Kalisch & Lee, 2012; Pearson, Needleman, Beckman, & Han, 2015). Total teamwork differed by hospital, F (11, 1,412) = 7.50, p < .0001; service line, F (8, 1,412) = 10.4, p < .0001; and unit F (45, 1,412) = 2.31, p < .0001. Figure 1 shows the total teamwork averages for the aggregate system (n = 1,414).

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4.2 | Teamwork across care settings (service lines)

ANOVA found significant differences in total teamwork between care settings (service lines) F (8, 1,412) = 10.40, p < .0001. Table 1 shows the mean calculations for each of the subscales of teamwork across service lines. Rehabilitation had the highest levels of total teamwork (M = 3.840) and continuing care (long term care) had significantly lower levels of total teamwork (M = 3.288).

4.3 | Aspects of effective teams: subscales

The aggregate averages for the five subscales are shown in Figure 1. All care settings showed similar trends in subscales. The mean (M) for the total system was highest for the shared

mental model subscale (M = 4.207, standard deviation [SD] of 0.582). Team leadership was also relatively higher within nurs- ing teams (M = 3.991, SD = 0.801) than the remaining subscales, the latter showing a higher sample variance (0.339 to 0.641 re- spectively). The subscales of back up, trust and team orientation generally showed a significant drop from shared mental model and leadership across the system. The trust and backup scales showed similar frequency of behaviours (trust M = 3.790/SD = 0.725; backup M = 3.754/SD = 0.783). Finally, there was a marked drop in team orientation behaviours, with a mean of 2.324 (SD = 0.732). Regardless of the unit type or service line, the trend in subscales was constant, which is a significant finding to support the notion that nursing teams are similar regardless of the setting. Table 1 provides the averages for each subscale within each care setting.

F IGURE  1 Total teamwork averages: system aggregate

4.21 3.99

3.75 3.79

2.32

3.61

Shared Mental Model

Team Leadership

Backup Trust Team Orienta�on

Total Teamwork

Total Teamwork Averages Shared Mental Model Team Leadership Backup

Trust Team Orienta�on Total Teamwork

TABLE  1 Teamwork across service lines

Service line

Shared mental model Leadership Backup Trust

Team orientation Total Teamwork

M SD M SD M SD M SD M SD M SD

System total (n = 1,414)

4.207 0.582 3.990 0.801 3.754 0.783 3.790 0.725 2.324 0.732 3.614 0.441

Rehabilitation (n = 44) 4.487 0.480 4.375 0.347 4.318 0.513 4.231 0.567 1.790 0.539 3.840 0.265

Adult MedSurg (n = 438)

4.335 0.517 4.024 0.591 3.911 0.714 4.001 0.630 2.114 0.651 3.677 0.373

Adult progressive care (n = 204)

4.241 0.563 4.063 0.572 3.799 0.746 3.831 0.721 2.282 0.739 3.643 0.390

Adult critical care (n = 214)

4.210 0.509 3.973 0.647 3.701 0.739 3.718 0.664 2.323 0.677 3.585 0.369

Women and infants (n = 107)

4.233 0.501 3.843 0.759 3.776 0.730 3.746 0.696 2.504 0.699 3.622 0.397

Paediatric critical care (n = 145)

4.107 0.552 3.886 0.617 3.652 0.731 3.667 0.645 2.487 0.737 3.559 0.343

Paediatric MedSurg (n = 64)

4.241 0.512 4.043 0.561 3.911 0.598 3.821 0.606 2.306 0.597 3.644 0.329

Continuing care (n = 105)

3.741 0.803 3.369 0.901 3.193 0.969 3.262 0.915 2.873 0.808 3.288 0.569

M, mean; SD, standard deviation.

     |  5KAISER And WESTERS

Figure 2 displays the trends in subscales across care settings. This graph shows a consistent and significant drop in team orientation among all nursing teams.

4.4 | Differences in teams based on demographics

ANOVA was used to compare average perceptions of total teamwork characteristics based on education, gender, age, experience and work descriptors. For each of these aggregate characteristics the Bonferroni method was used to adjust for multiple testing.

There was no significant difference in the average total teamwork among males (LSM = 3.50) and females (LSM = 3.53) p > 1.0, nor were there differences by level of education (p > .41–1.0). Nursing teams on night/third shift (LSM = 3.58) reported significantly higher levels of teamwork (p < .001) than those working on day/first shift (LSM = 3.46) or evenings/second shift (LSM = 3.47). The total team- work score for those with up to 2 years of experience (LSM = 3.58) was significantly higher than those with greater than 5 years of experience (LSM = 3.39), p > .05. Work characteristics such as the amount of work missed and the amount of overtime worked had no significant differences in overall teamwork.

4.5 | Teamwork and satisfaction

The average total teamwork score for those who had no plans to leave their position within the next year (LSM = 3.52) was significantly greater (p < .001) than the average total teamwork score of those who planned to leave their position within 6 months (LSM = 3.45, p > .40) or within the next year (LSM = 3.39, p > .014). The data showed a clear correlation (p < .001) between satisfaction with position and teamwork. There was sufficient evidence to show that the average total teamwork score was highest for those with higher perceptions of adequate staffing. All levels of perceived staffing adequacy showed significant difference with a clear decline in teamwork as perceptions of adequate staffing declines. These results have implications for job retention and satisfaction.

5  | CONCLUSIONS

Generally nursing teams had similar components to those of highly effective teams in other industries as defined by the standards de- scribed by Salas (Baker et al., 2006). However, there was variation in the degree to which the nursing team expressed each of these com- ponents. In highly effective teams these scales tend to be more evenly distributed (Baker et al., 2006; Jain et al., 2008; Salas et al., 2008). This presents an opportunity for improvement to make nursing teams more congruent with prototype teams used as a model of practice.

The shared mental model subscale scored highest across the sys- tem. The shared mental model is the structure of relationships and role responsibilities within a team. High scores in this subscale means that team members are clear on the responsibilities and tasks expected of themselves and others. They feel they work well together and respect and value each other as team members. One item of particular note scored markedly low on this subscale: ‘team members are aware of the strengths and weaknesses of other team members they work with most often’. This becomes important as discussed in subsequent sub- scales. It is significant to note that nursing teams tend to know whose task and whose patient is whose but have less of an awareness of each other as team members.

The team leadership subscale also scored consistently high, which implores discussion. The predominant literature on health care teams assigns the role of team leader to the physician or other medical pro- vider. This is reflected in practice. However, satisfaction with and efficacy of the physician/provider in providing the leadership skills necessary to facilitate true teamwork is lacking. More typical of this type of team is the role of the physician/provider to make decisions based on information provided by other group members, but not nec- essarily input provided by the same (Alexanian et al., 2015).

In contrast the NTS model assigns a charge nurse or nurse man- ager the role of team leader. While nurse team leaders were perceived as much more effective than the medical leaders of interprofessional teams there remains a discrepancy between nursing teams and non- health care highly effective teams. The leadership behaviours described

F IGURE  2 Trends for teamwork subscales across care settings

1.5

2

2.5

3

3.5

4

4.5

Shared Mental Model

Team Leadership

Backup Trust Team Orientation

Total Teamwork

Rehabilitation Adult MedSurg Adult Progressive

Adult Critical Care Women and Infants Pediatric Critical Care

Pediatric MedSurg Continuing Care

6  |     KAISER And WESTERS

in the NTS are very directive toward workload and team function. High scores in this subscale mean that the team leader (charge nurse, su- pervisor or manager) monitors progress, directs changes in the plan and structure of responsibilities, and determines who should do what. Conversely, a key feature of high- functioning teams is that they are self- regulating, self- adaptable and markedly less dependent on a di- rective leader. Salas describes the importance of a dedicated leader, but in the most effective teams this aspect does not overshadow the other components. The nursing teams in this study had a prominently higher score in leadership compared with the other subscales indicat- ing a dependence on leadership versus autonomous practice.

Subscales that scored lower across the nursing teams were backup and trust. The backup scale describes team members who willingly aid and help one another with their tasks and responsibilities. In partic- ular, members monitor for and recognize when someone is busy or overloaded and assist them in their work. When the workload is heavy both team members and leadership pitch in to get things done. These behaviours were not as evident in nursing teams. While the teams value each other there is a predominant mindset of clear role delin- eation and work assignments among nursing team members. Patients are assigned to nurses and nursing assistants, and licensure often de- termines task responsibility. Even within the same level and role, units operate based on the care needed for assigned patients. Nurses feel an obligation and often pressure to get everything done for their own patient. Work left undone for the next shift is chastised and there is a constant pressure to ‘get everything done on my shift’. In the survey the least prevalent behaviours were those in which the team members themselves monitored each other and were aware of function outside of their work assignment.

The trust subscale on this questionnaire is focused on commu- nication: team members trust each other enough to communicate ideas and information and value, seek and give each other construc- tive feedback, trusting that team members will receive feedback and change as needed for the good of the team (Kalisch et al., 2010). What is seen in a lower trust subscale is the lack of self- monitoring and self- correcting through good communication found in highly effective teams. Salas observed that feedback is essential for a team to function effectively. This sort of feedback is not generally part of the typical nursing unit culture as health care tends to function in a hierarchal system of power and regulation. A levelled hierarchy tends to be a prerequisite to teamwork and the lack of this dynamic is evident in the low scores of the trust subscale.

Team orientation was the lowest scoring subscale. Team orienta- tion describes a commitment to the goals and integrity of the team versus personal objectives. It includes open discussion of behaviours of team members, a supportive helpful attitude of collective responsi- bility, feedback between members and conflict resolution. Teams with high team orientation are more focused on the collective work than their own responsibilities (Kalisch et al., 2010). Essentially low team orientation scores indicate an individualist versus a collectivist mind- set. This collectivist orientation of teams is the key feature of effective teams as indicated by decades of team research (Salas et al., 2008). Nurses represent the largest group of professionals who provide

patient care and have the most direct interactions with patients on a daily basis. Thus nurses have an immense influence on patient out- comes. Yet the unique structures and attributes of nursing teams are relatively unexamined particularly in settings where the majority of patient care is received. This study provides a large sample of nurs- ing teams. This study affords a distinctive description of patient care teams comprising specifically nurses. Understanding the team dy- namics of nursing professionals and their support personnel offers a unique opportunity to understand and impact those who provide the most direct patient care.

The lack of correlation between teamwork and demographic fea- tures such as gender and education shows that the factors of highly effective teams are process- orientated and modifiable. The correla- tions between teamwork and variables such as job satisfaction and role satisfaction reinforce previous findings of the positive outcomes of teamwork (Korner et al., 2015), and have implications for retention.

What is most important to this study is the description of the struc- ture and dynamics of teamwork among nursing teams in acute care settings. The disproportionately high leadership scores among acute care nursing teams combined with lower subsequent subscales show that nursing team characteristics differ from the known attributes of highly effective teams. Salas’ Big Five Framework of Teamwork model was developed by observing the characteristics of highly functioning teams. For teamwork to be effective all the concepts and coordinating mechanisms must be evident (Rochon, Heale, Hunt, & Parent, 2015). The 74 units/areas examined in this study had a very broad range and variety of skill mix, education, experience and satisfaction. Regardless of these vast differences, every nursing unit showed a similar pattern in the elements of teamwork with shared mental model and leadership scoring highest, then a marked drop to backup and trust, followed by team orientation as the least prevalent element.

The nursing teams in this study reflect members who have a clear understanding of their responsibilities, work alongside each other re- spectfully and are well coordinated by their nurse leader. The data reflect a sense of ‘parallel work’ in that individuals do their own work and collaborate, communicate and share information for specific sit- uations. However, awareness and concern for other team members presents an opportunity for improvement. Members of the nursing team work alongside each other but are focused on their own pa- tient assignments and responsibilities. There is little awareness of other team members and backup behaviours to support others in their work are not often practised. Overall teams in this survey did not have a sense of higher purpose that transcends their personal work domain.

While this study uniquely examines the teamwork of nurses there are several limitations. No sampling techniques were used and the re- sponse rate was below 40%, which is generally considered the mini- mum rate to be representative. A proportion of respondents worked in the team for less than 6 months and may not have a full under- standing of the team dynamics. The results were based on responses to a survey rather than observations of team behaviours and may be influenced by the perceptions of the respondent. Finally, no outcomes were measured in this study – it is simply a description of nursing

     |  7KAISER And WESTERS

teams and does not explore the relationship between nursing team- work and important clinical and patient outcomes.

6  | IMPLICATIONS FOR NURSE LEADERS

The benefits to be realized from effective teamwork are well docu- mented and include improved client care and outcomes, professional growth, greater job satisfaction and positive organisational outcomes. Put broadly, synergy is the primary outcome of exceptional teamwork. Synergy occurs when a team’s output exceeds what can be accom- plished individually. Two critical attributes to a synergistic group in- clude group cohesion and the pursuit of a common goal (Witges & Scanlan, 2015).

The data from this study find that this goal orientation is lacking in nursing teams. In nursing and health care it is agreed that patient well- being, safety and ‘patient- centred care’ is a mutual, widely accepted and valued goal among team members. While paramount this concept is nebulous. General management strategies support the articulation of SMART objectives and goal settings but this is rarely done in pa- tient care. Yet anecdotal stories of excellence that focus on a particular patient experience have shown that nursing teams can work syner- gistically when there is a specific goal in mind. Nurse leaders are en- couraged to set daily SMART objectives for the unit that can be clearly realized and celebrated, to facilitate this sense of collective purpose.

A high level of group orientation is the key element lacking in the nursing teams of this study. The question to nurse leaders becomes how to achieve this level of collective orientation and cohesion. Only intentional attention to teams and teambuilding can achieve this. Studies have found that teamwork can be developed through individ- ual and team competency training (Baker et al., 2006; Gaston et al., 2016; Salas et al., 2008). TeamSTEPPS® Crew Resource Management, simulation and other training methods have been widely deployed in health care and have demonstrated positive results (Gaston et al., 2016). Unit- based team building interventions related to work expec- tations, communication, decision- making and conflict resolution have been successful in creating effective nursing teams. Modifying tasks, workflow or structure can also enhance teamwork (Baker et al., 2006). Leaders can examine the conditions in which team- based work occurs and re- design accordingly. Creating interdependencies creates the conditions for teamwork to exist.

One specific way to create conditions that require interdependen- cies is to redesign staffing structures. Researchers have suggested that teams who are more familiar with each other may function better than new teams (Rochon et al., 2015). Intuitively this makes sense and nurs- ing leaders have responded by concerning themselves with retention efforts to maintain employees. An even easier solution is to schedule the same individuals together. The size of the hospital unit has been found to impact teamwork, with smaller units having better teamwork (Kalisch et al., 2013). Common staffing practices do not base sched- ules on other employees resulting in an ever- changing group of in- dividuals who comprise the nursing team. This practice may in fact inhibit teamwork and should be considered.

A comprehensive model of team performance specific to nurs- ing teams in acute and continuing care needs to be fully developed to lay a scientific understanding of what compromises effective teamwork in these settings. This study begins to contribute to this work by describing nursing teams in relationship to Salas’ model of teamwork which has been widely accepted as a prototype in both health care and other high- reliability organisations. It is presumed that the development of the components of this model will lead to increased team performance. This assumption needs to be validated with further research. Nurse leaders can use the information from this study to focus on the areas for opportunity to build highly ef- fective nursing teams.

ACKNOWLEDGEMENTS

Karen Vander Laan, PhD, MSN, RN and Sarah Geoghan, BSN, RN.

ORCID

Jennifer A. Kaiser http://orcid.org/0000-0002-7686-0213

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How to cite this article: Kaiser JA, Westers JB. Nursing teamwork in a health system: A multisite study. J Nurs Manag. 2018;00:1–8. https://doi.org/10.1111/jonm.12582