Delivery of nursing care occurs in a highly complex environment that requires working together to accomplish the goals of nursing care. In the absence of teamwork, breaches in nursing care impact the quality of care delivered and compromises patient outcomes (Hessels, Flynn, Cimiotti, Cadmus, Gershon, 2015). As a global issue within the nurse practice environment, missed nursing care (MNC) is defined as care that is omitted (partially or totally) or delayed (Kalisch, Xie, & Ronis, 2013). Factors associated with MNC are related to teamwork (Kalisch, 2013), which entails team trust and communication (McComb et al, 2017). While nurses do not plan for MNC, one nurse alone or inadequate staffing cannot provide all the nursing care and demands that arise; thus, projecting a disjointed approach to care delivery (Winset et al, 2015). Therefore, an approach to nursing care delivery must reflect teamwork amongst nursing staff to meet the day-to-day challenges. It has been shown that higher teamwork leads to greater productivity, fewer errors, and more satisfied staff (Kaiser & Wester, 2018).
Prior to initiating this study, few methods of improving nursing teamwork in hospital patient care units had been tested. This concern was discussed amongst academia and practice members of the local nursing research consortium. After much deliberation, the decision to develop a collaborative nursing research study was undertaken to test an intervention, known as Team Tactics, to improve unit teamwork and reduce missed nursing care.
Design/Methods
The non-randomized intervention research received approval from the respective internal review structure of each Mid-west hospital (n=8) and the local university Institutional Review Board. Seven acute care medical centers and one critical access hospital in two adjacent Mid-west states participated. Medical, surgical, combined medical-surgical units, and critical care units, as defined by the National Database of Nursing Quality Indicators (Press Ganey, Kansas City), were eligible. Staffed beds in acute care centers ranged from 136 to 350; the critical access hospital staffed 25 beds. A total of 957 nurses and nursing assistants were eligible to participate in the study. Individual subject inclusion criteria were 1) registered nurse (RN) or nursing assistant (NA) that worked on an eligible unit; 2) worked at least 50% at the bedside; 3) worked a full-time equivalent status of 0.5 or greater; and 4) received information on study requirements and signed the study consent.
The teamwork intervention program, Team Tactics (Kalisch, Xie, & Ronis 2013), began with a 2-day train-the-trainer methodology session for key nurses and principal hospital leads. Participants were trained to identify and practice positive feedback and to disseminate the training on their study units. Once consented, participants completed the baseline questionnaire and attended the training sessions. Questionnaires were repeated at post intervention and follow-up time points. Trainers mentored all staff in using teamwork feedback during the normal work day. Principal leads performed three fidelity checks to ensure the intervention was consistently applied in their respective hospitals.
Three data points were collected: pre-intervention, one month following the intervention (post-intervention) and five months (follow-up) after the intervention period. Fifteen demographic and six-unit characteristics were collected at baseline. Two surveys were completed at all time points. The Nursing Teamwork Survey had 33 items in 5 subscales that asked for frequency of behaviors observed. Scores ranged from 0-4 with higher scores reflecting a more positive perception that the behaviors were present. Internal reliability by Cronbach alphas ranged from .77 to .82. MNC was assessed by the MISSCARE survey that asked respondents to rate the frequency of 24 elements of nursing care that were perceived to be missed by themselves or unit staff. Scores ranged from 0-4 with higher scores reflecting perception of more missed care. Internal reliability by Cronbach alpha was .93. Statistical analyses were performed with SPSS Statistics v22 (IBM Corp. Armonk, NY). Probability was set at 0.05 and effect size calculated with partial eta squared. Demographic and unit characteristics were described with percent, means, medians, and percentiles as determined by the data type with the general linear model univariate analyses. Survey items were analyzed with Friedman’s Two-Way Analysis of Variance by Ranks with Wilcoxon signed-rank tests used for post-hoc analysis with Bonferroni adjustment and reported by median and percentiles. Rho and Pearson’s correlation matrices were used to identify associated variables. Variables that were conceptually and statistically significant were placed in models. Standard multivariate regression models were developed to identify factors that contributed to the dependent variable Team Trust for critical care units and for medical-surgical units. After normality, linearity, homoscedasticity, and multicollinearity assessment, several iterations were explored.
Findings
Of eligible units, 26 participated (84.6%): four critical cares, eight medical, five surgical, and nine combined medical/surgical units. Of eligible participants, 650/957 (68%) consented of which 59 withdrew; leaving a remainder of 591 participants. Of these, 515 entered the online survey site and completed the first survey with 473 having usable data for sample description. Matched participants that completed all three surveys (n=185) were analyzed in the repeated measures analyses.
The mean age for the entire sample was 34.9 (11.3) years, with 387 (75%) nurses and 86 (16.6%) nursing assistants. Of the 77% degreed nurses, associate degree was the largest group (44.4%). Staffing was reported to be adequate 61.4% of the time. Twelve-hour day shift was the most frequent shift worked (55.1%). The majority of participants worked on the unit from 6 months to 5 years (50.4%) and in their role as RN or NA (46.5%).
There was no difference in the number of participating nurses among the unit types. Critical care had significantly less nursing assistants than all other units. No difference was detected for unit or RN full time equivalents among the units. Medical and surgical units had significantly less hours per patient day and RN hours per patient day, resulting in a significantly less skill mix.
The Nursing Teamwork Survey showed no differences across time periods (pre-intervention, post-intervention, and follow-up) for the teamwork subscale scores. MNC had a statistically significant decrease (less care elements missed) in the median total MNC scores across the three time periods x2 (2, n=136) =8.5, p= .014 with no differences among unit types.
The final model for factors that impact Team Trust (dependent variable) for critical care units were three variables: Pre-intervention Team Backup (r = .579), Leadership (r= .469), and Shared Mental Model (r= .618). These variables explained 38.6% of the variance in the model with pre-intervention shared mental model having the most unique contribution with a beta value of .427, p= .008. The final model for factors that impact Team Trust (dependent variable) for medical-surgical units were four variables: Post-intervention Backup (r= .718) and Orientation (defined as team cohesiveness) (r= -.380), and Pre-intervention Leadership (r= .367) and Adequacy of Staffing (r= .285). These variables explained 55.9% of the variance in the model with pre-intervention backup (beta = .639; p = .000) and adequacy of staffing (beta value= 188; p = .007) having the most unique contributions to the model.
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