Nurse staffing levels and teamwork: a cross-sectional study of patient care units in acute care hospitals

Nursing teamwork is essential in promoting patient-centered care: a cross-sectional study

BACKGROUND

There has been little research regarding nursing teamwork, despite its important role in multidisciplinary teamwork in healthcare settings and its significance in ensuring high-quality nursing care. This study aimed to determine the teamwork levels of Korean nurses and examine the relationship between nursing teamwork and patient-centered care while controlling for other individual and work-related factors.

METHODS

We conducted a cross-sectional analysis of online survey data. The study population consisted of 992 Korean registered nurses employed in hospitals who had a minimum of six months of clinical experience. We performed latent profile analysis to identify latent teamwork subgroups based on response patterns. We performed analysis of variance and Chi-square tests to examine differences in individual and work-related characteristics according to teamwork group. We used multiple linear regression to investigate how nursing teamwork could affect patient-centered care after controlling for covariates.

RESULTS

We identified three nursing teamwork subgroups: low, mid, and high. Nurses with a higher level of teamwork in their units tended to work fewer hours with more adequate staffing (F = 5.88, p = 0.003 for working hours; F = 7.68, p < 0.001 for staffing adequacy). There was a significant positive association between nursing teamwork and patient-centered care after controlling for personal and work-related characteristics. Compared with low teamwork, mid and high teamwork increased patient-centered care scores by 0.32 (95% confidence interval [CI] = 0.23-0.40) and 0.57 (95% CI = 0.48-0.66), respectively.

CONCLUSION

Our findings indicate that enhancing nursing teamwork can serve as an effective strategy for promoting patient-centered care. Providing nurse education and training to equip nurses with the necessary knowledge and skills for effective teamwork is a crucial step. Additionally, fostering management commitment to create a supportive working environment, including adequate staffing, can facilitate improved nursing teamwork and, subsequently, patient-centered care.

The Relationship of Nursing Teamwork and Job Satisfaction in Hospitals

Introduction

Teamwork is identified as a key contributor to patient safety and good teamwork is recognized as one of the presumptions of healthy work environment in nursing. The importance of job satisfaction in nursing has repeatedly been confirmed, but only recently has the association of job satisfaction and nursing teamwork been identified.

Objective

To identify the level of nursing teamwork in hospitals in Iceland and its relationship with job satisfaction.

Methods

This was a quantitative descriptive cross-sectional study. Data were collected with the Nursing Teamwork Survey administered to nursing staff in medical, surgical, and intensive care units in hospitals in Iceland. This study is based on data from 567 participants.

Results

A logistic regression analysis indicated that work experience on current unit and perceived staffing adequacy contributes to job satisfaction and when controlling for unit type, role, experience on current unit and staffing adequacy, those reporting better teamwork are significantly more likely to be satisfied with their current position. With an additional unit for overall nursing teamwork, participants are almost five times likelier to be satisfied with their current position.

Conclusion

Study findings show that there is a significant relationship between nursing teamwork and job satisfaction. The findings of this study confirm the importance of adequate staffing and good teamwork for nurses' job satisfaction. Staffing however, will remain the most challenging part of the equation as lack of nursing staff is foreseen globally in the coming decades turning the spotlight to teamwork. All stakeholders, including clinical nurse leaders, administrators, and instructors, need to emphasize on strengthening nursing teamwork. Good teamwork with increased job satisfaction may prevent turnover and shortage of nurses, an issue expected to grow during and following the COVID-19 pandemic. Facilitating good teamwork should be one of the priorities of every nurse leader.

Frequency, reasons, correlates and predictors of missed nursing care in Turkey: A multi-hospital cross-sectional study

AIM

We aimed to examine the frequency, reasons, correlates and predictors of missed nursing care in Turkey.

METHODS

This descriptive and cross-sectional study sample consisted of 1310 nurses working in inpatient units of 10 public, university and private hospitals in Istanbul. Data were collected using the Nursing Teamwork Survey-Turkish and the MISSCARE Survey-Turkish between February and June 2019. Descriptive analysis, parametric comparative analysis, correlational analysis and regression analysis were used to analyse the data.

RESULTS

The total occurrence of missed nursing care was 2.93 (on a scale of 1.00-4.00), which differed across 21 nursing care elements. The most frequently missed care was turning patients every 2 hours. Multiple regression analysis determined that nurses' tenure in the profession, patient-nurse ratio, days absent in the last 3 months and nursing teamwork significantly affected missed nursing care. Nursing teamwork alone accounted for 23.6% of the variance in missed nursing care.

CONCLUSIONS

The level of missed nursing care was found to be high, and labour resources issues were the most important reason. Nurse professionals should apply interventions to improve nurses' work environment factors such as patient-nurse ratio and nursing teamwork to reduce the incidence of missed nursing care.

Acute care nurses' perceptions of leadership, teamwork, turnover intention and patient safety - a mixed methods study

BACKGROUND

This study contributes to a small but growing body of literature on how context influences perceptions of patient safety in healthcare settings. We examine the impact of senior leadership support for safety, supervisory leadership support for safety, teamwork, and turnover intention on overall patient safety grade. Interaction effects of predictors on perceptions of patient safety are also examined.

METHODS

In this mixed methods study, cross-sectional survey data (N = 185) were collected from nurses and non-physician healthcare professionals. Semi-structured interview data (N = 15) were collected from nurses. The study participants worked in intensive care, general medicine, mental health, or the emergency department of a large community hospital in Southern Ontario.

RESULTS

Hierarchical regression analyses showed that staff perceptions of senior leadership (p < 0.001), teamwork (p < 0.01), and turnover intention (p < 0.01) were significantly associated with overall patient safety grade. The interactive effect of teamwork and turnover intention on overall patient safety grade was also found to be significant (p < 0.05). The qualitative findings corroborated the survey results but also helped expand the characteristics of the study's key concepts (e.g., teamwork within and across professional boundaries) and why certain statistical relationships were found to be non-significant (e.g., nurse interviewees perceived the safety specific responsibilities of frontline supervisors much more broadly compared to the narrower conceptualization of the construct in the survey).

CONCLUSIONS

The results of the current study suggest that senior leadership, teamwork, and turnover intention significantly impact nursing staff perceptions of patient safety. Leadership is a modifiable contextual factor and resources should be dedicated to strengthen relational competencies of healthcare leaders. Healthcare organizations must also proactively foster inter and intra-professional collaboration by providing teamwork educational workshops or other on-site learning opportunities (e.g., simulation training). Healthcare organizations would benefit by considering the interactive effect of contextual factors as another lever for patient safety improvement, e.g., lowering staff turnover intentions would maximize the positive impact of teamwork improvement initiatives on patient safety.

Conflict management and teamwork in workplace from the perspective of nurses

PURPOSE

To examine the relationship between nurses' conflict management strategies and teamwork attitudes.

METHOD

This cross-sectional, descriptive, and relational study was conducted with 228 nurses in a hospital in southern Turkey. Data were collected through The TeamSTEPPS Teamwork Attitudes Questionnaire and the Rahim Organizational Inventory-II.

RESULTS

Of all the nurses, 91.2% reported to have had conflicts. Nurses stated that they mostly used compromising and integrating strategies. Teamwork attitudes questionnaire mean score was 108.28 ± 11.45. Conflict management strategies are significant predictors of teamwork attitudes and these explain 46% (model 1; R²   = 0.46; P <.01), and education, gender, units, years of experience explain 2% of the total variance in teamwork attitudes (model 2; R²   = 0.48; P < .01).

PRACTICE IMPLICATIONS

Mental health nurses together with manager nurses should focus on improving nurses' teamwork attitudes and constructive conflict management strategies within the team.

Relational Quality of Registered Nurses and Nursing Assistants: Influence on Patient Safety Culture

Registered nurses (RNs) working within acute care hospitals have an incredible responsibility to provide safe care in a complex environment which requires trust, teamwork, and communication. Nursing assistants (NAs) play a critical role in working with RNs to meet these growing demands of inpatient care. Minimal evidence exists exploring the relational quality between RNs and NAs within hospitals. The aim of this study is to explore RN and NA behaviors and experiences that promote patient safety and teamwork and enhance communication between RNs and NAs within the hospital environment. Qualitative analysis was used, with two focus groups which included six participants within each group (three RNs and three NAs) from two separate inpatient units. Transcripts were reviewed and coded for themes. Collaborative teamwork and two-way communication were commonly reported as behaviors that promote patient safety. Trust between RNs and NAs was identified as a key component of positive relationships between RNs and NAs. Participants identified four common behaviors that build trust, which were accountability, effective conflict resolution, collaborative teamwork, and prioritizing patient needs. Finally, teamwork was identified as a common strategy to increase communication effectiveness between RNs and NAs. High relational quality (RQ) between the RN and NA is an important component of teamwork and patient safety culture.

Multilevel analysis exploring the relative importance of workplace resources in explaining nurses' workload perceptions: Are we setting the right focus?

BACKGROUND

Nurses' workload has become increasingly recognized as an important determinant of nurse turnover and shortage and has been also associated with poorer quality of care. Despite strong evidence that heavy workloads have negative consequences, we still lack a comprehensive understanding of the workplace characteristics that contribute most to improving nurses' workload, the relative importance of each in doing so, or indeed the workplace characteristics and other factors that drive nurses' perceptions of their workload.

PURPOSE

The aim of this study was to examine workplace resources as antecedents of nurses' perceptions of their workload and to investigate their relative importance in explaining workload perceptions. We considered workplace resources related to staffing, professional relationships, and technology.

METHODOLOGY

The study sample comprised nurse-reported and administrative data from U.S. Veterans Health Administration hospitals between 2014 and 2017. Our multilevel analyses are based on data from 20,330 nurses working in 273 work groups at 123 hospitals. We developed and empirically tested a theoretical model using multilevel mixed-effects linear regression. The relative importance of workplace resources was assessed by dominance analysis.

RESULTS

Staffing levels, relational climate, and information technology were significantly associated with nurses' workload perceptions. Dominance analysis indicated that relational resources are the most important measure in explaining nurses' workload perceptions.

PRACTICE IMPLICATIONS

This is the first study to examine the relative importance of workplace resources in explaining nurses' perceptions of their workload. Our results suggest that much might be gained by investing in interventions to boost relational resources. In turn, these findings could lead to more targeted, effective, and resource efficient interventions to improve nurses' workload.

The Association of Nurse-Physician Teamwork and Mortality in Surgical Patients

In this study we describe nurse-physician teamwork, estimate its association with surgical patient outcomes (30-day mortality and failure-to-rescue), and determine whether these relationships depend upon other modifiable hospital nursing characteristics (nurse staffing and education levels) known to be associated with patient outcomes. This cross-sectional analysis included linked data from 29,391 nurses representing 665 acute care hospitals and 1,321,904 adult patients who underwent a general surgical, vascular, or orthopedic procedure. Surgical patients cared for in hospitals with better nurse-physician teamwork had significantly lower odds of 30-day mortality (odds ratio [OR] = 0.95) and failure-to-rescue (OR = 0.95). In addition, the odds of death and failure-to-rescue were lower for patients in hospitals with both higher nurse-physician teamwork and more favorable patient-to-nurse staffing ratios. Similar trends were observed related to nursing education levels. Improving interprofessional teamwork is one strategy to improve patient outcomes with the added importance of also considering additional features of their nursing workforce.

Teamwork in nursing: essential elements for practice

As any nurse working in the NHS knows, teamwork can be powerful. Successful teamwork can make a huge workload of unmanageable tasks manageable. However, unsuccessful teamwork can leave people struggling to cope. This article explores readers' knowledge and skills related to teamwork and provides them with new skills and techniques to improve practice.

The extent to which adequacy of staffing predicts nursing teamwork in hospitals

AIMS AND OBJECTIVES

The purpose of this study was to examine the extent to which staffing adequacy predicts nursing teamwork, controlling for demographic and background variables.

BACKGROUND

Findings from former studies indicate that hospital, unit and staff characteristics may be related to nursing teamwork, such as type of hospital and unit, role, gender, age, work experience, type of shift worked, shift length, number of working hours per week, overtime and staffing adequacy. Teamwork as well as staffing is identified as significant contributors to patient and staff safety in hospitals. However, the contribution of staffing to the quality of nursing teamwork is scarcely studied.

DESIGN

This was a quantitative descriptive cross-sectional study using the paper-and-pencil questionnaire Nursing Teamwork Survey-Icelandic.

METHODS

The study was conducted in 27 inpatient units in eight hospitals in Iceland with a sample of 925 nursing staff members. Participants were 567 registered nurses, practical nurses, unit secretaries and nurse unit managers. The Strengthening the Reporting of Observational Studies in Epidemiology checklist was used for this paper.

RESULTS

When controlling for unit type, role, experience on current unit and intent to leave, perceived adequacy of staffing alone explains up to 10% of overall teamwork. Unit type, role, years of experience on current unit and perceived staffing adequacy correlated significantly with overall teamwork.

CONCLUSIONS

The findings of this study indicate that unit and staff characteristics, including perceived adequacy of staffing, are associated with and explain the variability in nursing teamwork on inpatient hospital units. The findings of this study provide important information for clinical nurses, nurse managers, policymakers and instructors in health care.

RELEVANCE TO CLINICAL PRACTICE

The findings underline the importance of adequate staffing for nursing teamwork in inpatient hospital units.

Collaboration among registered nurses and practical nurses in acute care hospitals: A scoping review

AIM

This study examined the extent, range, and nature of registered nurse (RN) and practical nurse (PN) collaboration in acute care hospitals and identified research gaps in the existing literature.

BACKGROUND

Optimal patient care requires collaboration between RNs and PNs. A lack of unity and unresolved tension among different types of nurses influences collaboration and has significant implications on practice and the organizations where nurses work.

METHODS

Using Arksey and O'Malley's (2005) framework, a scoping review was undertaken to answer the research question: what is known from the existing literature about the structures, processes, and outcomes of RN-PN collaboration in hospitals?

RESULTS

Twenty-nine studies were included with the majority coming from North America. Donabedian's model assisted with the identification of three themes: scope of practice, interpersonal skills, and nurse and patient-related outcomes.

CONCLUSION

The findings demonstrate there is a paucity of research specific to RN-PN collaboration. Nurse administrators/managers play an important role in addressing the interpersonal skills of nurses and providing an ongoing education on collaboration in the practice setting. Additional studies should focus on the development of nursing collaborative practice models of patient care, the examination of interventions to improve RN-PN collaborative practice, and the assessment of outcomes relating to collaboration among nurses.

‘You just can’t do it all’: a secondary analysis of nurses' perceptions of teamwork, staffing and workload

The purpose of this study was to re-examine data to explore connections between nurses’ perceptions of teamwork, staffing and workload, focusing on salient aspects and connections, from the nurses’ perspective. Insufficient staffing levels and imbalanced workload distributions are prominent challenges in contemporary healthcare which can cause increased incident reports, medical errors and lower patient satisfaction. Using a novel form of secondary analysis – an original qualitative analysis followed by a quantification of the qualitative data, we found themes of teamwork, staffing and workload were interrelated in the data. When facing workload challenges created by understaffing, participants directly attributed their units’ ability to meet the needs of patient care to levels of teamwork on the unit. We suggest that teamwork in healthcare needs targeted organisational support. In other words, healthcare organisations must systematically approach and monitor the status of nursing teamwork, e.g. implement programmes to develop it as needed, particularly when faced with staffing and workload challenges. Healthcare leaders can learn from and the healthcare delivery workplace can be shaped by listening to teamwork perceptions of nurses.

What facilitates the delivery of dignified care to older people? A survey of health care professionals

Background

Whilst the past decade has seen a growing emphasis placed upon ensuring dignity in the care of older people this policy objective is not being consistently achieved and there appears a gap between policy and practice. We need to understand how dignified care for older people is understood and delivered by the health and social care workforce and how organisational structures and policies can promote and facilitate, or hinder, the delivery of such care.

Methods

To achieve our objective of understanding the facilitators and to the delivery of dignified care we undertook a survey with health and social care professionals across four NHS Trusts in England. Participants were asked provide free text answers identifying any facilitators/barriers to the provision of dignified care. Survey data was entered into SPSSv15 and analysed using descriptive statistics. These data provided the overall context describing staff attitudes and beliefs about dignity and the provision of dignified care. Qualitative data from the survey were transcribed verbatim and categorised into themes using thematic analysis.

Results

192 respondents were included in the analysis. 79 % of respondents identified factors within their working environment that helped them provide dignified care and 68 % identified barriers to achieving this policy objective. Facilitators and barriers to delivering dignified care were categorised into three domains: ‘organisational level’; ‘ward level’ and ‘individual level’. Within the these levels, respondents reported factors that both supported and hindered dignity in care including ‘time’, ‘staffing levels’, training’,’ ‘ward environment’, ‘staff attitudes’, ‘support’, ‘involving family/carers’, and ‘reflection’.

Conclusion

Facilitators and barriers to the delivery of dignity as perceived by health and social care professionals are multi-faceted and range from practical issues to interpersonal and training needs. Thus interventions to support health and social care professionals in delivering dignified care, need to take a range of issues into account to ensure that older people receive a high standard of care in NHS Trusts.

An Examination of Supervisory Structures in Canadian Radiation Therapy Departments Using National Phone Interviews

BACKGROUND

Canadian radiation therapy departments usually have flat organizational structures, with relatively few administrative/managerial levels. The "unit supervisor" level is a typical job role that provides direct supervision of one or more treatment units with a mixture of clinical and administrative duties.

METHODS

At the British Columbia Cancer Agency, the unit supervisor role was recently evaluated. One approach used as part of the evaluative process was a series of telephone interviews to examine similar roles across Canada (n = 9).

RESULTS

Data indicated that departmental administrative tasks seem to be increasing significantly, and there is a move toward the addition of more administrative "middle" roles across the country to deal with these. Unit supervisor roles are subsequently becoming less clinical, but there is an emerging tension with moving away from solely clinical responsibilities and assuming more administrative work.

CONCLUSIONS

The historic unit supervisor role was part of the team and did little administrative work. This model is becoming difficult to sustain, and tensions can arise in this new environment when using old organizational models. Focused departmental clinical expertise is important; however, balancing clinical and administrative expectations within the unit supervisor role can be problematic. Role expectations need to be examined, clarified, and communicated within departments. If unit supervisor roles are deemed clinical experts, then clinical time needs to be protected for expertise to be sustained.

Measuring teamwork in health care settings: a review of survey instruments

BACKGROUND

Teamwork in health care settings is widely recognized as an important factor in providing high-quality patient care. However, the behaviors that comprise effective teamwork, the organizational factors that support teamwork, and the relationship between teamwork and patient outcomes remain empirical questions in need of rigorous study.

OBJECTIVE

To identify and review survey instruments used to assess dimensions of teamwork so as to facilitate high-quality research on this topic.

RESEARCH DESIGN

We conducted a systematic review of articles published before September 2012 to identify survey instruments used to measure teamwork and to assess their conceptual content, psychometric validity, and relationships to outcomes of interest. We searched the ISI Web of Knowledge database, and identified relevant articles using the search terms team, teamwork, or collaboration in combination with survey, scale, measure, or questionnaire.

RESULTS

We found 39 surveys that measured teamwork. Surveys assessed different dimensions of teamwork. The most commonly assessed dimensions were communication, coordination, and respect. Of the 39 surveys, 10 met all of the criteria for psychometric validity, and 14 showed significant relationships to nonself-report outcomes.

CONCLUSIONS

Evidence of psychometric validity is lacking for many teamwork survey instruments. However, several psychometrically valid instruments are available. Researchers aiming to advance research on teamwork in health care should consider using or adapting one of these instruments before creating a new one. Because instruments vary considerably in the behavioral processes and emergent states of teamwork that they capture, researchers must carefully evaluate the conceptual consistency between instrument, research question, and context.

Communication and psychological safety in veterans health administration work environments

Purpose

– The purpose of this paper is to explore employee perceptions of communication in psychologically safe and unsafe clinical care environments.

Design/methodology/approach

– Clinical providers at the USA Veterans Health Administration were interviewed as part of planning organizational interventions. They discussed strengths, weaknesses, and desired changes in their workplaces. A subset of respondents also discussed workplace psychological safety (i.e. employee perceptions of being able to speak up or report errors without retaliation or ostracism – Edmondson, 1999). Two trained coders analysed the interview data using a grounded theory-based method. They excerpted passages that discussed job-related communication and summarized specific themes. Subsequent analyses compared frequencies of themes across workgroups defined as having psychologically safe vs unsafe climate based upon an independently administered employee survey.

Findings

– Perceptions of work-related communication differed across clinical provider groups with high vs low psychological safety. The differences in frequencies of communication-related themes across the compared groups matched the expected pattern of problem-laden communication characterizing psychologically unsafe workplaces.

Originality/value

– Previous research implied the existence of a connection between communication and psychological safety whereas this study offers substantive evidence of it. The paper summarized the differences in perceptions of communication in high vs low psychological safety environments drawing from qualitative data that reflected clinical providers’ direct experience on the job. The paper also illustrated the conclusions with multiple specific examples. The findings are informative to health care providers seeking to improve communication within care delivery teams.

Nursing teamwork and time to respond to call lights: an exploratory study

AIM

The aim of this exploratory study was to determine whether the level of nursing teamwork is correlated to call light answering time in acute care hospital patient care units.

BACKGROUND

Teamwork has been shown to improve productivity. In this study, we examine the relationship between unit call light response time as a measure of productivity and the level of teamwork on the unit.

METHOD

The Nursing Teamwork Survey was administered to nursing staff on 18 inpatient units in 3 hospitals. In addition to the overall teamwork score, the NTS has 5 subscales. Call light response times were collected from electronic systems which measures the time it takes for nursing staff on a given unit to respond to patient call lights.

RESULTS

There was no significant relationship between call light response time and teamwork overall or on the five subscales. Shared mental models, which comprise the conceptual understanding of the roles and responsibilities of each team member, however was moderately correlated with call-light answering times.

CONCLUSIONS

It is logical that shared mental models would be associated with call light response time since a common problem in patient units is the "it's not my job syndrome" where nursing staff do not answer call lights for patients assigned to someone else. More research with a larger number of patient units is needed to validate these findings.

Night and day in the VA: associations between night shift staffing, nurse workforce characteristics, and length of stay

In hospitals, nurses provide patient care around the clock, but the impact of night staff characteristics on patient outcomes is not well understood. The aim of this study was to examine the association between night nurse staffing and workforce characteristics and the length of stay (LOS) in 138 veterans affairs (VA) hospitals using panel data from 2002 through 2006. Staffing in hours per patient day was higher during the day than at night. The day nurse workforce had more educational preparation than the night workforce. Nurses' years of experience at the unit, facility, and VA level were greater at night. In multivariable analyses controlling for confounding variables, higher night staffing and a higher skill mix were associated with reduced LOS.

A leadership challenge: staff nurse perceptions after an organizational TeamSTEPPS initiative

The purpose of this study was to measure RNs' perceptions of teamwork skills and behaviors in their work environment during a multiphase multisite nursing organizational teamwork development initiative. Teamwork is essential for patient safety in healthcare organizations and nursing teams. Organizational development supporting effective teamwork should include a just culture, engaged leadership, and teamwork training. A cross-sectional survey study of bedside RNs was conducted in one 5-hospital healthcare system after a TeamSTEPPS teamwork training initiative. TeamSTEPPS teamwork training related to improved RN perceptions of leadership. Initiatives to align the perspectives and teamwork efforts of leaders and bedside nurses are indicated and should involve charge nurses in the design.

Nursing intellectual capital theory: operationalization and empirical validation of concepts

AIMS

To present the operationalization of concepts in the nursing intellectual capital theory and the results of a methodological study aimed at empirically validating the concepts.

BACKGROUND

The nursing intellectual capital theory proposes that the stocks of nursing knowledge in an organization are embedded in two concepts, nursing human capital and nursing structural capital. The theory also proposes that two concepts in the work environment, nurse staffing and employer support for nursing continuing professional development, influence nursing human capital.

DESIGN

A cross-sectional design.

METHODS

A systematic three-step process was used to operationalize the concepts of the theory. In 2008, data were collected for 147 inpatient units from administrative departments and unit managers in 6 Canadian hospitals. Exploratory factor analyses were conducted to determine if the indicator variables accurately reflect their respective concepts.

RESULTS

The proposed indicator variables collectively measured the nurse staffing concept. Three indicators were retained to construct nursing human capital: clinical expertise and experience concept. The nursing structural capital and employer support for nursing continuing professional development concepts were not validated empirically.

CONCLUSION

The nurse staffing and the nursing human capital: clinical expertise and experience concepts will be brought forward for further model testing. Refinement for some of the indicator variables of the concepts is indicated. Additional research is required with different sources of data to confirm the findings.