Transformational Teams: Examining the Relationship of Nursing Teamwork to Patient Outcomes

Saturday, 7 November 2015

Debbie J. Rahn, MSN, EdD, RN, FABC
School of Health Sciences, Reading Health System, Reading, PA, USA

Over one decade ago, a landmark study in healthcare identified the need for the healthcare industry to address a widespread problem of preventable adverse patient outcomes.  The problem of preventable negative patient outcomes continues to pervade American healthcare, and there is an identified need to better understand the relationship of soft skills, such as nursing teamwork, and the occurrence of patient outcomes. The success of future educational and leadership interventions to improve patient outcomes is dependent on first identifying key factors associated with the negative patient outcomes.

The purpose of this research was to investigate the relationship of nursing teamwork within acute care medical-surgical nursing units and specific nurse-sensitive patient outcomes including pressure ulcers, patient falls, and catheter-associated urinary tract infections.  The primary research question of this study was: How does nursing teamwork affect nurse-sensitive patient outcomes?  The study builds upon a theoretical framework entitled The Donabedian Model of Patient Safety which describes a linear progression from input concepts to outcome concepts, implying that each input component (such as teamwork) has a direct influence on the outcome.  In addition, more contemporary research by Salas, Sims, and Burke in 2005 defined teamwork by identifying eight constructs or elements of teamwork, and provided the foundation for a theoretical understanding of nursing teamwork.

The non-probability convenience sample included in this research was that of nursing team members currently employed in acute care medical-surgical environments.  Participants were derived from a single 735-bed acute care community hospital located in mid-eastern United States.  The methodologies utilized in this study included the following datasets: (1) teamwork survey (quantitative), (2) nurse-sensitive patient outcome data secured from the research site’s pre-existing National Database of Nursing Quality Indicators (NDNQI) data (quantitative) and (3) sequential follow-up focus group interviews (qualitative).  The mixed methodology design utilized comparison of means and correlational statistical analysis to compare eight medical-surgical nursing units’ teamwork data (collected using the teamwork survey) with each unit’s NDNQI nurse-sensitive patient outcome data.  The nurse-sensitive outcome data incorporated as dependent variables included pressure ulcers, falls, and urinary catheter associated infections. 

Strategies for assurance of ethical standards focused on securing informed consent, protecting the participant’s right to withdraw, anonymity of survey data, confidentiality, and conducting the study with integrity and the avoidance of deceptive practices.  The primary limitation associated with the proposal was related to the single-site study design.  The lack of a strict scientific empirical framework and unit-based data analysis also limited causal inferences among the variables.

The raw data supported the premise that a pattern exists whereby medical-surgical nursing teams with higher levels of teamwork as measured by the teamwork survey is accompanied by a pattern of fewer negative nursing outcomes. The clinical impact and clinical significance of this raw data finding is important to discuss.

Several important correlations were noted between constructs of teamwork and patient outcomes. Examples include the correlational findings between the independent variable of intra-shift teamwork and the dependent variable of unassisted falls.  The two variables were moderately correlated, r (8) = -.618, p < .05 (two tailed) and demonstrated an inverse relationship as represented by the negative correlation value. A second finding was the result of correlational data analysis between a teamwork construct and unassisted falls.  The Kendall’s Tau-b correlation between the teamwork construct and unassisted patient falls was -.571.  The finding was statistically different from zero (τb = -.571, n = 8, p= .048) and indicated a moderate inverse relationship between the two variables.

Additional statistical analysis was conducted to identify specific variables as described in each teamwork survey question. Analyzing each question as an independent variable provided more specific information regarding teamwork behaviors which may be associated with outcomes. These relationships were computed utilizing the Pearson Product–Moment Correlation Coefficient to determine if a relationship existed between the variables.  Several findings were significant in all three types of negative patient outcomes. 

These relationships, along with the prior evidence established in nursing and healthcare literature, as well as the already established high personal and organizational stakes for negative patient outcomes, lead one to believe that the null hypothesis should be rejected.  The clinical relevance of that finding is that there may be value in investing time, energy, and resources in educational and leadership strategies aimed at improving teamwork within the medical–surgical nursing sector, with the goal of improving patient outcomes. 

The research also provided rich qualitative data regarding the role of nursing teamwork in the provision of high quality patient care. The research data suggests that according to the nurse’s perspective, teamwork is a critical influential factor of patient outcomes.  The research findings suggest that teamwork in the medical surgical nursing teams mirrors the research completed in other areas of healthcare demonstrating a relationship between teamwork and outcomes.   

Key findings induced through triangulation of the quantitative and qualitative data included differing levels of teamwork among teams, transitory nature of nursing team membership, three descriptive themes related to high quality teams, the importance of team leadership, barriers to teamwork, the lack of skill in dealing with conflict between team members, and the unmet educational needs of nursing team members. Four primary conclusions provide a framework for teamwork education, interventions, and future research.  Four major conclusions relate to the impact of teamwork on nurse-sensitive patient outcomes, the lack of a standard theoretical model of team performance within the nursing profession, the need to adapt team training strategies to address the unique needs of nursing teams, and the need for implementation of additional strategies related to the educational needs of nursing team members.    

The concept of Transformational Teamwork emerged from the evidence and conceptualizes teamwork within a system where a transformational leader influences not only individual followers, but influences the team as a whole to perform optimally, resulting in high quality outcomes.  Each team member within a transformation team has a positive influence on the team and other team members, and the success of transformational teamwork is measured by quality outcomes.  

The research has important clinical and practical implications for the nursing profession and healthcare consumers. Recommendations for the future address nursing practice, education, and leadership as well as define additional future research.  Although the design and methodology of the research prevents making any generalizable connections, the research has generated an interest in further exploring the connection between nursing teamwork and nurse sensitive outcomes including pressure ulcers, falls, and catheter associated infection.  In addition, the findings reveal some areas for potential improvements, curriculum development, and educational and leadership interventions.

It is critical that the nursing profession examine the incidence of negative patient outcomes occurring within the nursing sector’s locus of control, and implement educational and leadership strategies to protect patients from the resulting increased morbidity and mortality commonly associated with negative patient outcomes.