Train-the-trainer intervention to increase nursing teamwork and decrease missed nursing care in acute care patient units.

Nursing Research November/December 2013 Vol 62, No 6, 405–413

Train-the-Trainer Intervention to Increase Nursing Teamwork and Decrease Missed Nursing Care in Acute Care Patient Units Beatrice J. Kalisch

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Boqin Xie

b Background: Teamwork is essential for patient safety and results in less missed nursing care. b Objectives: The aim of this study was to test the impact of a train-the-trainer intervention on the level of satisfaction with nursing teamwork and the amount of missed nursing care. b Methods: This study used a quasiexperimental design with repeated measures taken at pretest, posttest, and 2 months after completion of the intervention. The sample for this study was the nursing staff on three medicalYsurgical units in three separate acute care hospitals (one unit in each hospital). Three nurses from each unit underwent a training program and then taught the skills and knowledge they acquired to the staff members on their units in three-hour-long sessions. The training involved staff role-playing scenarios based on teamwork problems that occur regularly on inpatient units in acute care hospitals followed by debriefing, which focused on teamwork behaviors (e.g., leadership, team orientation, backup, performance monitoring) and missed nursing care. Four measures were used to test the efficacy of this intervention: The Nursing Teamwork Survey, the MISSCARE Survey, and questions about the knowledge of and satisfaction with teamwork. Return rates for the surveys ranged from 73% to 84%. Follow-up tests individually comparing pretest, posttest, and delayed posttest were conducted within the mixed model and used the Bonferroni correction for multiple comparisons. b Results: Teamwork increased (F = 6.91, df = 259.01, p = .001) and missed care decreased (F = 3.59, df = 251.29, p = .03) over time. Nursing staff also reported a higher level of satisfaction with teamwork and an increase of teamwork knowledge after the intervention. b Discussion: The intervention tested in this study shows promise of being an effective and efficient approach to increase nursing teamwork and decrease missed nursing care. b Key Words: hospitals & nursing care & quality of care & teamwork

I

t has been widely recognized that teamwork is essential for patient safety. The Institute of Medicine (IOM) study, ‘‘To Err is Human,’’ pointed to the need for enhanced teamwork in healthcare to avoid patient errors (IOM, 2000). The follow-up report by the IOM also clearly indicated that

4

David L. Ronis

nurses are indispensable to patient safety (IOM, 2001). Higher self-identified teamwork in the intensive care unit was found to be related to lower patient mortality rates (Wheelan, Burchill, & Tilin, 2003). A group-type hospital culture was found to predict fewer patient falls with injury (Brewer, 2006). Other studies have shown the connection between higher teamwork and patient safety (e.g., Auerbach et al., 2012; Blegen et al., 2010; Kalisch, Tschannen, & Lee, 2012; Weaver et al., 2010) and higher quality of care (Brewer, 2006; Schmutz & Manser, 2013; Wheelan et al., 2003). A systematic review of 28 studies on the impact of team processes on clinical performance (e.g., fall rates, morbidity, mortality) found that ‘‘every study reported at least one significant relationship between team processes and performance’’ (Schmutz & Manser, 2013, p. 529). Despite the rising interest in teamwork and recognition of its importance, most studies of teamwork in healthcare have focused on emergency (Reznek et al., 2003) and perioperative/anesthesia settings (e.g., Awad et al., 2005; Blum et al., 2004; Hansen, Uggen, Brattebo, & Wisborg, 2008; Howard, Gaba, Fish, Yang, & Sarnquist, 1992). There has also been a study in the labor and delivery settings (Nielsen et al., 2007). There has been, however, very little attention given to teamwork on inpatient units in acute care hospitals where a substantial proportion of healthcare is delivered. Given the fact that there are an estimated 50,000 (6,000 acute care hospitals on average of eight to nine inpatient units each = 50,000 units; American Hospital Association, 2013) such teams in the United States alone providing nursing care to patients, their impact on patient safety and quality of care is potentially enormous. Other benefits of higher teamwork are increased job and occupation satisfaction and lower turnover and vacancy rates among nursing staff members (Gifford, Zammuto, & Goodman, 2002; Kalisch & Curley, 2008; Kalisch, Lee, & Rochman, 2010). Patients have been found to be more satisfied when teamwork is higher (Meterko, Mohr, & Young, 2004).

Beatrice J. Kalisch, PhD, RN, FAAN, is Titus Distinguished Professor and Director, Innovation and Evaluation, University of Michigan, Ann Arbor. Boqin Xie, MS, RN, is PhD Student; and David L. Ronis, PhD, is Research Scientist, School of Nursing, University of Michigan, Ann Arbor. DOI: 10.1097/NNR.0b013e3182a7a15d

Nursing Research November/December 2013 Vol 62, No 6

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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406 Intervention to Increase Nursing Teamwork Missed nursing care (errors of omission) is defined as any aspect of required standard nursing care that is not completed (Kalisch, Landstrom, & Williams, 2009). Studies have indicated that a large amount of care is being missed in acute care hospitals in the United States and other countries (Kalisch, Doumit, Lee, & Zein, 2013; Kalisch, Terzioglu, & Duygulu, 2012; Kalisch, Tschannen, Lee, & Friese, 2011; Schubert et al., 2013). A study of the impact of nursing teamwork on missed nursing care showed that the higher the teamwork, the less the missed nursing care (Kalisch & Lee, 2010). Specifically, controlling for occupation of staff members (e.g., registered nurses [RNs], licensed practical nurses [LPNs], nursing assistants [NAs]) and staff characteristics (e.g., education, shift worked, experience), teamwork alone accounted for 11% of the variance in missed nursing care (Kalisch & Lee, 2010). In another study, focus groups were conducted with the staff on the five (of 110) patient care units with the most missed nursing care and the five with the least missed nursing care (located in five hospitals). The key difference was that the units with the least missed nursing care reported and described a much higher level of teamwork (Kalisch, Gosselin, & Choi, 2012). Using the Nursing Teamwork Survey (NTS; Kalisch, Lee, & Salas, 2010), nursing staff on 52 patient care units in five hospitals (77% RNs and LPNs, 12% NAs, and 8% unit secretaries [USs]) were surveyed. Teamwork varied across units and service types (lower teamwork scores on medicalYsurgical and emergency units) and shifts worked (greater teamwork scores in 8- or 10-hour shifts, part-time staff, and night shifts). The highest teamwork scores were associated with none or little overtime and a decreased absenteeism (Kalisch & Lee, 2009). There have been many studies with the goal of increasing teamwork outside of the healthcare industry and, to a lesser degree, within healthcare. A review of approaches used to improve the effectiveness of teams in healthcare found that the interventions included training (e.g., simulation, crew resource management [CRM], other training) and the use of tools to enhance teamwork (e.g., checklists, goal sheets, case analysis) and organizational interventions (e.g., workflow assessment and redesign and/or reconstruction of care teams; Buljac-Samardzic, Dekker-van Doorn, van Wijngaarden, & van Wijk, 2010). Several studies specifically evaluated the effect of TeamSTEPPS, an interdisciplinary healthcare training program supported by the Department of Defense and the Agency of Healthcare Research and Quality (AHRQ, 2012; Clancy, 2007). After receiving a version of TeamSTEPPS training in the pediatric and surgical intensive care units, staff perceptions of teamwork were improved and the average time for placing patients on extracorporeal membrane oxygenation and the rate of nosocomial infections were decreased significantly (Mayer et al., 2011). A hospital in Iraq used the program in one hospital for 13 months and reported significant decreases in the rates of communication-related errors, medication and transfusion errors, and needle stick incidents (Deering et al., 2011).There was a significant improvement in the operating room staff teamwork and communication, clinical outcomes, and patient satisfaction 9 months after the implementation of TeamSTEPPS (Armour Forse, Bramble, & McQuillan, 2011). Very few studies, however, have focused on teamwork within nursing. After a thorough review of the research on interven-


tions to enhance teamwork, Buljac-Samardzic et al. (2010) observed that one of the key gaps in research in healthcare teamwork is the lack of studies of monodisciplinary (singlediscipline) teamwork. They found only three such studies (two in nursing and one in anesthesiology), including test of a team building intervention with staff nurses associated with improvement in group cohesion and nurse-to-nurse interaction (DiMeglio et al., 2005). Gibson (2001) discovered that a goal setting intervention was not related to group effectiveness. One study evaluated an intervention (a combination of training, an engaged guiding team, and coaching) to increase teamwork and engagement. It resulted in a significant decrease in patient falls, staff vacancy, and turnover rates and a significant rise in staff ratings of the level of teamwork (Kalisch, Curley, & Stefanov, 2007). The drawbacks to this intervention were the considerable length of time and the high use of resources required (i.e., staff time, outside consultant time). In another study on a medicalYsurgical patient care unit, an hour of team training using virtual simulation led to an increase in nursing teamwork but no decrease in missed nursing care (Kalisch et al., under review). Finally, comparing a group of nurses who participated in a TeamSTEPPS workshop with those who had not, leadership improved significantly but communication, mutual support, situation monitoring, and team structure did not increase (Castner, Foltz-Ramos, Schwartz, & Ceravolo, 2012). These data suggest that TeamSTEPPS alone is insufficient to address nursing care delivery problems in inpatient settings. Conceptual Framework The conceptual framework, depicted in Figure 1, hypothesizes that a train-the-trainer intervention will lead to a higher level of nursing teamwork and a lower level of missed nursing care, which in turn will lead to staff (nursing satisfaction, lower intent to leave their jobs) and patient outcomes (falls and falls with injury, etc.). The context variables include unitlevel case mix index (as a proxy for patient acuity), level and type of staffing, and nursing staff characteristics (education, age, experience, etc.). In this study, an intervention to increase teamwork and decrease missed nursing care and the impact on satisfaction was tested. The content of the tested intervention is based on the Salas, Sims, and Burke (2005) model of teamwork, which provides a practical behavioral and precise explanation of teamwork, including five core components: (a) team leadership, (b) collective orientation, (c) mutual performance monitoring, (d) backup behavior, and (e) adaptability. These core teamwork behaviors are coordinated with three mechanisms: (a) shared mental models, (b) closed loop communication, and (c) mutual trust. A qualitative study of inpatient nursing teams (RNs, LPNs, and NAs) on five different patient care units established that this theoretically based model of teamwork is a relevant and appropriate means of describing nursing teamwork in inpatient hospital units (Kalisch, Weaver, & Salas, 2009). Research Question The question of this research study was as follows: Does a train-the-trainer teamwork/missed care intervention for nursing staff on inpatient hospital units result in (a) a higher level of



Intervention to Increase Nursing Teamwork 407

FIGURE 1. The missed nursing care/teamwork model.

teamwork, (b) less missed nursing care, (c) more satisfaction with teamwork, and (d) greater knowledge of teamwork?

Methods Design This study used a quasiexperimental design with repeated measures taken at pretest, posttest, and 2 months after completion of the intervention. The unit of analysis was the individual nursing staff member.

Measures Four measures were used to test the efficacy of this interventionVthe NTS, the MISSCARE Survey, and questions about satisfaction with teamwork and knowledge about teamwork. Questions about staff characteristics (e.g., age, gender, education, job experience), work schedules (shift and hours worked), and staffing (absenteeism, intention to leave, perceived staffing adequacy) were contained in the demographic section of the surveys.

NTS The NTS was specifically designed to measure nursing

Setting and Sample The sample for this study was the nursing staff on three medicalYsurgical units in three separate acute care hospitals (one unit in each hospital). The hospitals included an academic medical center (beds: 9900), a specialty hospital (beds: 980), and a large teaching hospital (beds: 91000). There were no specific criteria used to select the units within the hospitals other than the type of patients cared for. All members of the nursing teams who provide direct patient care on these units (RNs, LPNs, NAs) were recruited to be subjects for this study. Although nurse managers and USs may not provide direct patient care, they are part of the nursing team. Hence, they also completed NTS (not the MISSCARE Survey). The nursing team for this study was defined as those individuals who work on a given patient care unit as permanent members (as opposed to staff members who move from unit to unit such as physicians, floating staff members, physical therapists, occupational therapists, dieticians, etc.). The return rates were 83.1% for the pretest surveys, 84.4% for the posttest, and 73.3% for the follow-up. The rates of completed training are 85.1% in Hospital 1, 54.7% in Hospital 2, and 41.3% in Hospital 3.

teamwork in inpatient settings. The NTS is a 33-item questionnaire with a five-level Likert-type scaling system (1 = rarely, 2 = 25% of the time, 3 = 50% of the time, 4 = 75% of the time, and 5 = always). The NTS contains five subscales: trust (i.e., shared perception that members will perform actions necessary to reach interdependent goals and act in the interest of the team; seven items), team orientation (i.e., cohesiveness, individuals see the team’s success as taking precedence over individual needs and performance; nine items), backup (i.e., helping one another with their tasks and responsibilities; six items), shared mental models (i.e., mutual conceptualizations of the task, roles, strengths/weaknesses, and processes and strategy necessary to attain interdependent goals; seven items), and team leadership (i.e., structure, direction, and support provided by the formal leader or the other members of the team, or both; four items). Exploratory factor analysis produced a five-factor solution, and these five factors explained 53.11% of the variance. Confirmatory factor analysis confirmed the factor structure (comparative fit index = 0.88, root mean square error of approximation = 0.06, standardized root mean square residual = 0.05). The testYretest reliability was .92. Reliability estimated


408 Intervention to Increase Nursing Teamwork using coefficient alpha was .94, and the alpha for the subscales ranged from .74 to .85. More details about the reliability and validity of the NTS have been published elsewhere (Kalisch, Lee, & Salas, 2010). MISSCARE Survey Missed nursing care is an error of omission and is defined as any aspect of required patient care that is omitted (either in part or whole; Kalisch, 2006). It has been shown that missed nursing care mediates the relationship between nurse staffing and patient falls (Kalisch et al., 2012). It has also been shown that higher staffing levels leads to less missed nursing care (Kalisch, Tschannen, & Lee, 2011b) and lower missed care results in higher staff satisfaction (Kalisch, Tschannen, & Lee, 2011a). The MISSCARE Survey was used to measure the phenomena. The survey is made up of 24 items where nursing staff were asked to identify how frequently nursing care elements were missed (e.g., ambulation three times a day, on-time administration of medications, repositioning and turning, patient assessments, iv site care, patient education, discharge planning). Respondents were asked to check the best response: always missed, frequently missed, occasionally missed, rarely missed, or never missed. The instructions for respondents were as follows: ‘‘To the best of your knowledge, how frequently are the following elements of nursing care MISSED by the nursing staff (including you) on your unit? Check only one box for each item.’’ In a study of the psychometric properties of the tool, acceptability was high. Factor analysis with Varimax rotation was conducted and confirmed by confirmatory factor analysis. Cronbach’s " values ranged from 0.64 to 0.86, and contrasting validity was established. The testYretest coefficient for the missed care score was 0.87 (Kalisch & Williams, 2009).Validity and reliability of the MISSCARE Survey have been reported elsewhere in detail (Kalisch & Williams, 2009). Satisfaction With Teamwork Nursing staff were asked how satisfied they were with the level of teamwork on their units. Responses were made on a Likert scale rating from 1 = very dissatisfied to 5 = very satisfied. The testYretest reliability of this item (measured as part of the psychometric analysis of the MISSCARE Survey) was 0.92 for satisfaction with teamwork (Kalisch, Lee, & Rochman, 2010). Knowledge of Teamwork The teamwork knowledge ques-

tionnaire was developed for this study and contained 15 questions. The items were multiple choices and focused on the eight behaviors of teamwork. It was a modification of the knowledge test contained in the AHRQ TeamSTEPPS instructor guide (AHRQ, 2012). The score of the knowledge test was the numbers of questions the participants answered correctly. Intervention The content and approach of the training intervention tested in this study was a customization of that used by CRM training, including TeamSTEPPS. However, CRM varies greatly from program to program and has no generally agreed upon content or format. However, these programs usually include simulation exercises, group debriefings, and instructional sections on topics, such as communication and so forth (Maynard,


Marshall, & Dean, 2012). The description of the intervention tested in this study is discussed below. Format The training format, which was pretested with a smaller group of nursing staff, consisted of limited didactic presentations, scenarios including role playing (simulation), debriefing, and discussion. The use of role playing (simulation) has been shown to result in a higher level of engagement of the trainees and requires more personal involvement in their learning. This approach could also reduce traditional hierarchical levels between RNs and NAs by having RNs play NA roles and vice versa. These materials customized existing team training programs, including TeamSTEPPS, by utilizing examples occurring regularly among nursing team members in the acute care hospital settings. Before the actual training, the staff members were asked to view a short (10-minute) podcast placed on the unit’s computers, defining and giving examples of nursing teamwork behaviors. In the first training session, the behaviors were briefly reviewed again and then two to three scenarios were utilized in the 1-hour session. (Subsequent sessions also used three to four scenarios in the same way.) As mentioned above, these scenarios were real-life situations that occur in inpatient nursing teams on a regular basis and were drawn from observations and focus groups with nursing staff in numerous hospitals (e.g., a nurse sitting at the desk, a call light goes off but it is not that nurse’s patient, she does not answer it because ‘‘it’s not my patient’’; a patient needs a bedpan, but the nurse in the room feels it is not her job, and she hunts all over the unit for an NA instead of doing it herself). The procedure was to provide the scenario and assign a role to each of the trainees (actor, observer). Those assigned to roles played them out according to the scenario for the rest of the group. Then, the nurse trainers reviewed each of the eight elements of teamwork one by one, asking the group to evaluate whether that behavior was present or not. They were then asked if any care was missed and if it was because of a teamwork problem. Finally, the players repeated the scenario incorporating the learning. By the time the trainees had gone through 9Y12 scenarios (in the three sessions), they had repeatedly reviewed the teamwork behaviors, the potential connection to missed nursing care, and practiced interacting in a more effective manner. Practicing feedback was a central component of the training. The eight team behaviors, as well as the method of feedback, were posted on the wall to facilitate the review. Training Class Size The training took place with groups of

three to six staff members. Most sessions had four or five staff members. This allowed all of attendees of the session to be involved in role playing, observing, and debriefing. It was also a reasonable number of staff members who could be released for an hour to attend the training sessions. Trainers There are generally two main approaches to who

will conduct trainingVusing outside facilitators or using a train-the-trainer model. The later approach was used for several reasons. First, the cost is lower. Second, it was believed that the trainers were staff members. They would be




ongoing resources who could provide advice in real time, thus potentially improving sustainability. The trainers were staff nurses who volunteered to assume this role. Two were from day shifts and one was from night shifts on each of the study units. All nine nurses attended a 2-day training session where they were not only exposed to the content and learning approaches but also showed the training itself, important for fidelity. Length Each nursing staff member was invited to participate

in three sessions, each 1 hour in length over a 4- to 6-week period. Location Because of cost constraints and shortage of nursing staff, hospitals have difficulty providing nursing staff time to leave their patient care units, especially in large numbers, for educational purposes. In addition to the logistical barriers, the cost of a full-day training for 80 people is approximately $25,000. With this intervention, the staff stayed on their units and received the relatively brief (1 hour each three) training sessions during their work time. The nurse managers or clinical nurse specialists covered for the staff nurses while they were in the training sessions. At other times, it was possible for the staff nurse to fit this into their 12-hour work time by covering patients for one another. On occasion, when a patient’s acuity increased or a large number of admissions occurred, the session was cancelled.

Procedures After acquiring institutional review board approval at the three study hospitals, three nurses from each study units were selected and trained together in a 2-day session followed by the staff training on the units. Scheduling of these sessions was completed by the trainers on each unit along with available support staff and managers. The first time the trainer completed a session, the principal investigator or a research assistant was present to ensure fidelity of the intervention. The pretest, posttest, and follow-up test were administered to all of the nursing staff (whether they participated in the training or not) on each unit. A cover letter explaining the study and a consent form to sign (along with one for them to keep) was provided along with the surveys. Follow-up reminders were posted on the unit. To protect the anonymity of the responses, the participants were asked to place their completed surveys into a letter-sized envelope and seal it before placing in a locked box on each unit. Also, because it was essential to match subjects across time, an identification code that only they would know (birth month, mothers’ birth month, and mothers’ first name) was used instead of the respondent’s name. The incentive for completion of each of the surveys was $5. In addition, those participants who completed all three training sessions received an additional $15.

data. However, many staff filled out fewer than all three surveys (only 85 of 242 completed all three). Thus, 85 subjects could be included in the repeated measures ANOVA, and both power and representativeness of the sample would be decreased. So instead, a mixed model analysis was performed using SPSS version 20, which allowed for the use of the data from all 242 subjects. Thus, all the data collected could be used to increase power and the representative of the sample. To uncover the missing pattern of our data set, a missingness variable was created to represent the number of surveys the participants did not complete. The chi-squared tests were conducted to examine the independence of missingness variable with hospital and demographic variables. It was found that the missingness variable was nonsignificantly associated with hospital, education, age, gender, shift hours, and experience. But, fewer NAs completed the surveys as did part-time staffs. Also, one-way ANOVA revealed that there were no significant differences in baseline teamwork, missed nursing care, and satisfaction with teamwork by the missingness variable. Hence, missing data were treated as missing at random in the mixed model analyses. Regarding the different rates of completed training in hospitals, the interaction variable of time with hospital was created, and a mixed model analyses was conducted using time, hospital, and interaction variable of time with hospital as fixed effects to examine if the effect of time differed by hospital. It was found that the main effect of hospital and the effect of the interaction variable were nonsignificant, which indicated that the effects of time on teamwork, missed nursing care, teamwork satisfaction, and teamwork knowledge did not differ by hospital. Therefore, the hospital variable was excluded from the presented model. Follow-up tests individually comparing pretest, posttest, and delayed posttest were conducted within the mixed model using restricted maximum likelihood estimation, and the mixed model simply considered the intercept as a random effect and time as a fixed effect. The model for each of the outcomes Yti on each occasion t for each individual i was

Yti ¼ "0i þ "1 ðTIME2Þ þ "2 ðTIME3Þ þ (ti ; where "0i is the individual baseline and "1 and "2 are shared offsets at posttest and delayed posttest, respectively, from the individual baselines. Variances for the "0i and for the *ti were estimated. The variances for the *ti were assumed to be equal for all i and at each t. Time was treated as categorical to look of nonlinear trends in time and mean differences between each time point. Bonferroni correction was used for multiple comparisons. Each outcome variable constituted a family of the post hoc comparison. The family-wise error rate after the Bonferroni correction was .05.

Results Data Analysis The design of the study was pretest, posttest, and delayed posttest measurements with the NTS, the MISSCARE Survey, and teamwork satisfaction and teamwork knowledge questionnaire. The train-the-trainer intervention was provided in all three units between the pretest and posttest measures. Repeated measures ANOVA of the data would require complete

Staff and Unit Characteristics The sample consisted of 242 nursing staff members who completed at least one survey in three hospitals. There were 52 (21.5%) participants in Hospital 1,105 (43.4%) in Hospital 2, and 85 (35.1%) in Hospital 3. The staff and unit characteristics are summarized in Table 1. The sample was made up of 65% RNs, 30% NAs, 4% USs, and 1% LPNs. The


410 Intervention to Increase Nursing Teamwork


q

q

TABLE 1. Demographic Characteristics Characteristic Hospital Hospital 1 Hospital 2 Hospital 3 Gender Male Female Age, years e44 Q45 Highest degree in nursing LPN diploma RN diploma Associate’s degree in nursing BSN Bachelor’s degree outside of nursing MSN or higher in nursing Job title/role Staff nurse/RN Staff nurse/LPN Nursing assistants Nursing manager, assistant manager Unit clerk/secretary Work hours per week Less than 30 hours 30 hours or more Experience in role Up to 6 months 96 monthsY2 years 92Y5 years 95Y10 years 910 years Experience on current unit Up to 6 months 96 monthsY2 years 92Y5 years 5Y10 years 910 years Shifts 8-hour shift 10-hour shift 12-hour shift 8-hour and 12-hour rotating shift Overtime None 1 hourY12 hours More than 12 hours

TABLE 1. continued

n

%

52 105 85

21.5 43.4 35.1

25 213

10.5 89.5

162 78

67.5 32.5

6 11 50 82 10 8

3.6 6.6 29.9 49.1 6.0 4.8

152 3 73 4 9

63.1 1.2 30.3 1.7 3.7

45 194

18.8 81.2

18 34 46 63 80

7.5 14.1 19.1 26.1 33.2

30 34 57 72 45

12.6 14.3 23.9 30.3 18.9

81 5 122 32

33.8 2.1 50.8 13.3

108 90 43

44.8 37.3 17.8

Characteristic Absenteeism None 1 day or shift (in the last 3 months) 2Y3 days or shift 3Y6 days or shifts Over 6 days Intention to leave In the next 6 months In the next year No plan within the year Staff adequate 100% of the time 75% of the time 50% the time 25% of the time 0% of the time

n

%

108 46 62 16 9

44.8 19.1 25.7 6.6 3.7

9 21 209

3.8 8.8 87.4

25 142 45 20 5

10.5 59.9 19.0 8.4 2.1

Note. N = 242. RN = registered nurse; LPN = licensed practical nurse; MSN = Master of Science in Nursing; BSN = Bachelor of Science in Nursing.

percentage of women was 89.5%, and over 50% of participants held a baccalaureate degree in or outside of nursing (55.1%). Outcomes Teamwork The main effect of time on overall teamwork was significant (F = 6.91, df = 259.01, p = .001), indicating that significant increases of overall teamwork took place in all three hospital units after pretesting (Table 2). The marginal means for pretest overall teamwork was 3.56 (SE = .04, 95% CI [3.48, 3.63]). The overall teamwork for the posttest increased by .06 (p = .089, 95% CI [j0.04, 0.13]) and teamwork for the delayed posttest from pretest increase by .13 (p G .001, 95% CI [0.06, 0.20]). Bonferroni tests showed the significant difference between pretest and delayed posttest (p G .05), reflecting improvements in overall teamwork of nursing staff from pretest to delayed posttest (Table 3). Moreover, the subscale scores of trust, team orientation, backup, and team leadership significantly improved over time period, whereas no significant changes in shared mental models existed after pretest (Table 2). The details of mixed model analysis of teamwork and subscales were presented in Table 2. Missed Nursing Care Missed nursing care changed significantly over the time period (F = 3.59, df = 251.29, p = .029), representing the significant decreases in missed nursing care after pretest (Table 2). The marginal mean of missed nursing care for pretest was 2.36 (95% CI [2.29, j2.43]). From the pretest, the missed nursing care decreased by .06 (p = .054, 95% CI [j0.13, j0.01]) for posttest and reduced by .09




(p = .011, 95% CI [j0.15, j0.02) for delayed posttest. The Bonferroni multiple comparisons showed that there was a significant difference between pretest and delayed posttest (Table 3).

were relevant to them (Martin, 1994; Roberson & Sundstrom, 1990). In other words, NAs and part-time nurses may have less issue salience with the topics of the surveys and were thus less motivated to complete them. A train-the-trainer Our intervention had characteristics intervention was provided Satisfaction With Teamwork Satisfaction of CRM training, including TeamSTEPPS. with teamwork increased significantly and resulted in a However, as Maynard and colleagues over time (F = 6.62, df = 283.08, p = point out, it is difficult to do an ‘‘apples significant increase in .002). The details of mixed model analto apples’’ comparison of various CRM ysis were listed in Table 2. Pairwise teamwork. programs (Maynard et al., 2012, p. 73.). comparisons showed the significant inThere are major variations in these procrease in satisfaction with teamwork from grams (e.g., length, trainers [external or pretest to posttest (p = .011) and from train the trainer], extent of tailorization). pretest to delayed posttest (p = .003; They conclude that it is ‘‘unlikely that a Table 3). qqq ‘one size fits all’ CRM program is possible’’ (Maynard et al., 2012, p. 73). The preliminary work in designing the intervention tested Teamwork Knowledge Teamwork knowledge increased sigin this study led to the center of the intervention around realnificantly over time (F = 5.36, df = 263.28, p = .005; Table 2). life scenarios that regularly occur with nursing teams on inpaThe marginal mean of knowledge for pretest was 9.94. tient units. In the development phase, the general healthcare There was a significant increase in knowledge from pretest scenarios from TeamSTEPPS and the nursing scenarios deto posttest based on Bonferroni test (Table 3). veloped with a small group of nurse were compared. It was found that nursing staff responded more favorably and felt they learned more when the scenarios were specifically on Discussion teamwork problems they faced on a regular basis. It is recA train-the-trainer intervention was provided on three ognized that there is a need for a study that compares various patient care units in three acute care hospitals and resulted approaches for specific audiences before any conclusions can in a significant increase in teamwork over and on four of be made. five subscales (trust, orientation, backup, shared mental The intervention has several advantages. It offers potenmodels, and leadership) and a significant decrease in missed tial sustainability in that there is an ongoing presence of the nursing care. It also resulted in a higher satisfaction with trainers on the unit who become internal mentors, change teamwork on the unit and a higher level of teamwork knowlchampions, and opinion leaders after the formal training was edge. In addition, the findings that NAs and nurses working completed. The fact that teamwork increased and missed part time had lesser survey completion rates may be because care decreased more from time 2 (immediately after training) of a lower level of issue salience or believing that the subjects to time 3 (2 months later) may be attributable to the ongoing

q

TABLE 2. Mixed Model Analyses of Teamwork, Missed Nursing Care, Teamwork Satisfaction, and Knowledge

Outcome Overall teamwork Trust Orientation Backup SMM Leadership Missed care Satisfaction Knowledge

Intercept Coefficient, 95% CI 3.56, 3.48, 3.30, 3.43, 4.01, 3.66, 2.36, 3.75, 9.84,

[3.48, [3.38, [3.19, [3.32, [3.93, [3.55, [2.29, [3.63, [9.50,

3.63] 3.59] 3.41] 3.53] 4.09] 3.76] 2.43] 3.88] 10.19]

Posttest Coefficient, 95% CI 0.06, 0.10, j0.02, 0.14, 0.04, 0.09, j0.06, 0.21, 0.51,

[j0.04, 0.13] [0.01, 0.19] [j0.13, 0.10] [0.04, 0.24] [j0.04, 0.11] [j0.02, 0.20] [j0.13, 0.01] [0.07, 0.34] [0.19, 0.84]

Delayed Posttest Coefficient, 95% CI 0.13, 0.13, 0.13, 0.21, 0.08, 0.14, j0.09, 0.24, 0.40,

[0.06, 0.20] [0.03, 0.22] [0.01, 0.25] [0.10, 0.31] [j0.01, 0.15] [0.03, 0.26] [j0.15, j0.02] [0.10, 0.38] [0.06, 0.74]

F

df

p

6.91 3.71 3.51 7.85 1.89 3.29 3.59 6.62 5.36

259.01 253.97 269.80 257.59 252.12 283.64 251.29 283.08 263.28

.001* .026* .031* .001* .154 .039* .029* .002* .005*

Note: N = 242. CI = confidence interval; SMM = shared mental models. *p G .05.


412 Intervention to Increase Nursing Teamwork


q

TABLE 3. Estimated Marginal Means and Bonferroni Correction of Teamwork, Missed Nursing Care, Teamwork Satisfaction, and Knowledge Pretest Outcome Overall teamwork Trust Orientation Backup SMM Leadership Missed nursing care Teamwork satisfaction Knowledge

Posttest

Delayed Posttest

M

SE

M

SE

M

SE

3.56a 3.48a 3.30a 3.43a 4.01a 3.66a 2.36a 3.75a 9.84a

0.04 0.05 0.06 0.05 0.04 0.05 0.04 0.07 0.18

3.62ab 3.58ab 3.28a 3.57b 4.05a 3.75ab 2.30ab 3.96b 10.35b

0.04 0.05 0.06 0.06 0.04 0.05 0.04 0.07 0.18

3.69b 3.61b 3.43a 3.64b 4.09a 3.80b 2.27b 3.99b 10.24ab

0.04 0.06 0.06 0.06 0.04 0.06 0.04 0.07 0.19

Note. N = 242. Means that do not share subscripts differ at p G .05 using the Bonferroni correction for multiple comparisons. SE = standard error; SMM = shared mental model.

presence of these individuals. Another advantage is the efficiency and cost effectiveness of the intervention. The training was only 3 hours in length and took place during work hours on the patient care units, and the use of internal nursing staff members avoided the costly alternative of using external trainers. Use of real-life regular occurrences may have led to a higher level of transfer to training from classroom to the work setting. The fact that the training took place in small groups created opportunity for greater involvement of each individual. Use of short repeated training sessions, as opposed to a longer 3-hour session, may have allowed for greater ability to maintain focus on the training. It also could have provided reinforcement of the learning.

Limitations This study was limited by the fact that it takes place in three hospital units and, thus, cannot be generalized broadly. Another limitation is that the hospitals and the units were not selected randomly and there were no control groups. A larger study of randomly selected patient care units with the addition of control units is needed to validate these findings. The measures of missed nursing care and nursing teamwork are based on staff opinions and are, therefore, susceptible to distorted perceptions. These potential limitations are provided in the context of the following strengths: extensively validated and published methods and measures and a compelling conceptual model that strengthens the science of nursing care delivery in acute hospital setting.

Conclusion Teamwork on acute care nursing units is essential to patient safety and quality care. A train-the-trainer intervention to enhance teamwork is feasible and shows promise of being an

effective and efficient approach to increase teamwork and decrease missed care events in acute care settings. q

Accepted for publication July 31, 2013. The authors acknowledge that funding was provided by the Blue Cross Blue Shield of Michigan Foundation. The authors have no conflicts of interest to disclose. Corresponding author: Beatrice J. Kalisch, PhD, RN, FAAN, Nursing Business and Health Systems, School of Nursing, University of Michigan, 400 N. Ingalls Street, Ann Arbor, MI 48109 (e-mail: [email protected]).

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