Team behavioral norms: a shared vision for a healthy patient care workplace

Leaders are bombarded with healthy workplace articles and advice. This article outlines a strategy for laying the foundation for healthy patient care workplaces at the pivotal unit level. This process facilitates the nursing unit staff to create and implement a shared vision for staff working relationships. Fourteen acute care hospital units, all participants in a healthy workplace intervention, were selected for this analysis because they chose team behavioral norms as a top priority to begin to implement their vision for a desired future for their units, a healthy workplace. These units developed specific team behavioral norms for their expectations of each other. The findings revealed 3 major norm themes and attributes: norms for effective communication, positive attitude, and accountability. Attributes of each norm are described to assist nurses to positively influence their core unit work culture.     

Rapid response team for behavioral emergencies

Behaviors of patients with psychiatric illness who are hospitalized on nonbehavioral health units can be difficult to address by staff members. Instituting a rapid response team to proactively de-escalate potential volatile situations on nonpsychiatric units in a hospital allows earlier treatment of behavioral issues with these patients. The behavioral emergency response team (BERT) consists of staff members (registered nurses, social workers) from behavioral health services who have experience in caring for patients with acute psychiatric disorders as well as competence in management of assaultive behavior. BERT services were trialed on a medical pulmonary unit; gradual housewide implementation occurred over 2 years. Tools developed for BERT include an activation algorithm, educational cue cards for staff, and a staff survey. Results of a performance improvement survey reveal that staff nurses have had positive experiences with BERT but that many nurses are still not comfortable caring for psychiatric patients on their units.     

The impact of team building on communication and job satisfaction of nursing staff.

A series of team-building activities were conducted on a medical-surgical unit and their impact on staff's communication and job satisfaction was examined. Forty-four unit personnel participated in the interventions. Staff communication and job satisfaction were measured before and after the intervention. The findings linked team-building activities with improved staff communication and job satisfaction. Team-building strategies assisted the nurse leader/manager to build an effective work team by strengthening communication and interpersonal relationships so that the staff could function as a more cohesive group. Staff development consultants can help nurse managers become more effective team leaders by identifying the necessary resources and by helping to plan and coordinate team-building strategies.     

A pluralistic evaluation of nursing/practice development units

Nursing/practice development units (N/PDU) are perceived as centres for pioneering, evaluating and disseminating innovative practice development and facilitating the professional development of practitioners. This paper reports on a pluralistic evaluation research study of the nursing/ practice development unit accreditation programme provided by the University of Leeds, UK. Individual and focus group interviews were undertaken with key stakeholders involved in six nursing/practice development units. These included: clinical leaders, team members, executive nurses, trust board members, general medical practitioners, nursing/practice development unit steering group members, and accreditation panel members. Stakeholder perceptions of what constituted a successful nursing/practice development unit were elicited and then used to judge the success of the programme. Seven criteria for judging the success of nursing/practice development units were identified. These were: achieving optimum practice; providing a patient-orientated service; disseminating innovative practice; team working; enabling practitioners to develop their full potential; adopting a strategic approach to change and autonomous functioning. The findings highlighted differences between the rhetoric of a successful nursing/practice development unit and the reality in which they function. Whereas all the units were actively involved in innovative practice development, evaluation, dissemination and networking activities, several factors influenced the success of the units, in particular, the role of the clinical leader, the motivation and commitment of nursing/practice development unit members, financial resources, and the nature of support from managers, medical staff and education institutions. Although the nursing/practice development units had made significant progress in developing both healthcare practice and practitioners, there is still a need to consider how the claim that nursing/practice development units benefit patients can be substantiated.     

Understanding the impact of power in organizations.

Although implementation of Shared Governance appears to have failed, it failed primarily on the surface. Many staff nurses actively involved in the Shared Governance movement not only were empowered but were dramatically affected on a professional level. Several council chairpersons were empowered to assume management roles in the transition back to the hierarchial model--a manifestation of their professional growth and development. At the unit level, several units lobbied the new leadership to allow them to continue to do peer review and unit-based council management of unit governance issues. Three councils lobbied to continue to do their work, although in a modified role, in the reestablished hierarchial structure. The three remaining councils were those of Practice, Quality, and Research. If nurse leaders at any level within the organization are to guide their departments forward while in the throes of the current chaos in health care, they must develop and use their power bases, both formal and informal, as individuals and then as leaders. Russell Coile identifies the need for more clinical expertise (expert power) on the executive team of health care organizations. He predicts that 50% of the executive team will be nurses and physicians and that only health care executives with an MBA or financial backgrounds, who also have well-developed informal power bases with skills in relationship development, facilitation, and networking, will be part of the new system. Those with a diversified informal power base will be most successful in guiding their organization to its destination. The future for nursing leaders is in the sharing of information; it is about embracing diversity and recognizing the contributions others can make that are refreshingly different; it is also about clearly defining a balance in life, because balanced leaders who have found a way to nurture and meet their own needs are better positioned to do the same for others. Ultimately, understanding the impact of power in an organization, regardless of organizational structure, begins with understanding and defining your own power base.     

The link between teamwork and patients' outcomes in intensive care units.

BACKGROUND: Links between teamwork and outcomes have been established in a number of fields. Investigations into this link in healthcare have yielded equivocal results. OBJECTIVE: To examine the relationship between the level of self-identified teamwork in the intensive care unit and patients' outcomes. METHOD: A total of 394 staff members of 17 intensive care units completed the Group Development Questionnaire and a demographic survey. The questionnaire is a reliable and valid measure of team development and effectiveness. Each unit's predicted and actual mortality rates for the month in which data were collected were obtained. Pearson product moment correlations and analyses of variance were used to analyze the data. RESULTS: Staff members of units with mortality rates that were lower than predicted perceived their teams as functioning at higher stages of group development. They perceived their team members as less dependent and more trusting than did staff members of units with mortality rates that were higher than predicted. Staff members of high-performing units also perceived their teams as more structured and organized than did staff members of lower-performing units. CONCLUSIONS: The results of this study and other establish a link between teamwork and patients' outcomes in intensive care units. The evidence is sufficient to warrant the implementation of strategies designed to improve the level of teamwork and collaboration among staff members in intensive care units.     

Relationships among teams, culture, safety, and cost outcomes

The objective of this study is to test the transtheoretical integration model, which proposes relationships among team-based phenomena and patient safety and resource-use outcome variables. The sample consisted of 411 nursing staff (n = 372) and multidisciplinary team members (n = 39) from 16 medical surgical units. Staff were surveyed to evaluate their perceptions of hospital culture, work group design, and positive and negative team processes. Managers provided data concerning outcome variables of patient falls with injury, average length of stay (LOS), and labor and supply expenses for their patient care units. A group-type hospital culture predicted fewer patient falls with injury; a developmental-type hospital culture predicted higher patient care unit costs. Team design and processes were predictive of longer LOS for patients on medical-surgical units. Conclusions of the study were that hospital contexts external to the patient care unit may be important contributors to patient safety and resource use on nursing units.     

Supporting newly hired nurses: a program to increase knowledge and confidence while fostering relationships among the team

BACKGROUND. It is important for newly hired nurses to be supported throughout their first year of employment by nurse leaders on their team. Newly hired nurses struggle with application of new clinical skills and critical thinking skills as well as integrating into unit culture. PROGRAM DESIGN. The Post Orientation Education Program (POEP) provided 18 newly hired nurses with clinical knowledge and support through one‐on‐one meetings with the nurse leaders on their unit. The nurse leaders discussed common diagnoses, laboratory tests, and medications in addition to providing support to the newly hired nurses as they adapted to the newness of nursing. Early in their career the newly hired nurses developed relationships with the leadership team that may have taken longer if not for the POEP. The program gave the newly hired nurses an opportunity to experience different teaching styles of the nurse leaders and offered them the chance to engage in conversations about both clinical and nonclinical information. OUTCOMES. The program was evaluated through pre/post tests and written evaluations. Evaluations revealed increased knowledge about common diagnoses, increased confidence in role, and the development of trusting relationships with the leadership team. CONCLUSION. The newly hired nurses valued the time that they spent with the leadership team as it helped them to integrate into the unit and feel comfortable using the leaders as resources for patient care. The POEP proved to be a program that impacted not only relationships among the team, but it increased retention and quality of patient care as the nurses felt supported by the team, knowledgeable about the care they were delivering and confident in their ability to seek out resources. A program like the POEP could be adapted to various healthcare settings based on individual needs of the team.     

Using Simulation Training to Improve Perioperative Patient Safety

Simulation learning provides medical and nursing personnel with the opportunity to develop and refine their skills without putting patients at risk. Faced with ensuring the competence of a large number of new staff members, the management team at one facility implemented a simulation training program. Surgical team members are able to participate in an ongoing program of simulated scenarios involving surgical drape fires and airway fires, cardiac arrest of patients in the supine position and prone position, respiratory depression in the postanesthesia care unit, and malignant hyperthermia. The simulations help OR staff members identify problems that can happen during real emergencies and help them work as a team to prepare for events that may represent life-threatening situations for patients.     

Error reduction in the New World. How we can improve the level of safety for everyone in our operating rooms

In order to do no harm, ask yourself and your colleagues the following questions: Is our environment safe? Does staff follow all safety measures? Do physicians and visitors follow safety rules? Is every staff member aware of their role in safety for all? Is there an effective staff/leader safety inspection team in place and functioning effectively? Are all reasonable recommendations implemented? Have the errors been reviewed in detail? If so, what were the results and what changes were made? Is self-reporting encouraged without repercussions? Do you know what your error rates are, what the root causes were, which systems were lacking, and how they have been modified? Needless to say we have a great deal of work to do and many challenges to overcome if we are to decrease our risk of error. But where to start? Do a critical analysis of the current system and, on a daily basis, focus on improving some small piece of the safety network that will have a lasting impact. The commitment and participation of staff, strong visible leadership, and accountable, well-trained individuals and teams will all be major contributors to a safe environment.     

Learning to Observe in Context: Child and Adolescent Inpatient Mental Health Assessment

On child and adolescent inpatient psychiatric units, nursing staff have 24-hour exposure to patients, an excellent vantage point for observing behavior in a variety of situations and interpersonal contexts. How staff members respond to milieu behaviors depends in part on their judgment of what prompted a youngster's response and his/her ability to process the event and control the attendant emotions. To assess such aspects of a child or adolescent's presentation requires that staff appraise not just the presenting behavior but the patient's information-processing and affect-regulation abilities. One way this developmental knowledge can be embedded in practice is through assessment guides that contain observation cues for key issues related to how children/adolescents think, feel, and behave. This article sets down the rationale for the content and organization of such inpatient nursing assessment guides and suggestions for their dissemination to the unit staff.     

Impact of healthy work environments and multistage nurse residency programs on retention of newly licensed RNs

The objective of the study was to examine effects of nurse-confirmed healthy unit work environments and multistage nurse residency programs (NRPs) on retention rates of newly licensed RNs (NLRNs). Establishing a culture of retention and healthy clinical nurse practice environments are two major challenges confronting nurse leaders today. Nurse residency programs are a major component of NLRN work environments and have been shown to be effective in abating nurse turnover. Sample for this study consisted of 5,316 new graduates in initial RN roles in 28 Magnet? hospitals. There were no differences in retention rates by education or patient population on clinical unit. NLRN retention rate was higher in community than in academic hospitals. More than half of NLRNs were placed on units with very healthy work environments. Newly licensed RNs on units with work environments needing improvement resigned at a significantly higher rate than did other NLRNs. The quality of clinical unit work environments is the most important factor in NLRN retention.     

Storytelling: A Strategy for Caring Connection in Creative Nursing Leadership

Using stories of nursing-involved situations is a powerful strategy for leaders to engage with their team members around their shared discipline. An environment conducive to storytelling facilitates the continuing engagement of members of the nursing staff in the human connection of caring in nursing. This article shares the story of a nursing-involved situation lived by several nurse leaders and interprets the situation in terms of caring creative leadership.     

Rehabilitation unit staff attitudes toward substance abuse: changes and similarities between 1985 and 2001

OBJECTIVES: (1) To assess the attitudes of the members of an inpatient rehabilitation unit team toward their unit's substance abuse and tobacco use policies, and (2) to compare the findings with those of a survey 16 years earlier. DESIGN: An anonymous repeated assessment of staff attitudes and behaviors. SETTING: A 47-bed inpatient rehabilitation unit. PARTICIPANTS: Rehabilitation unit nurses, occupational and physical therapists, psychologists, physicians, social workers, and speech pathologists. INTERVENTIONS: Not applicable. Main Outcome Measure: Change in response with time. RESULTS: Seventy percent (89/128) of the staff members completed the survey. Seventy-two percent believed that they were "familiar or very familiar" with the unit's substance abuse policy and 51% were "concerned" or "very concerned" about their patients' alcohol and drug use. Nineteen percent reported complaints about the policy from their patients and 8% reported complaints from family members. Support for a uniform substance abuse policy remained high: 96% supported a uniform policy in both 1985 and 2001. However, only 15% believed that staff drug abuse education was adequate and only 45% believed that the current policy was "adequate" or "very adequate." (Corresponding responses in 1985 were 20% and 50%, respectively.) All but 1 respondent considered tobacco use an addiction, but only 48% believed that their patients were routinely assessed for its use. CONCLUSION: Support for a uniform substance abuse policy remains strong. Although most team members support the policy, they believe that their education about substance abuse is inadequate. Staff members almost unanimously accept tobacco use as an addiction, but they believe that assessment and intervention efforts are poor.     

Key High‐efficiency Practices of Emergency Department Providers: A Mixed‐methods Study

Objective

The objective of this study was to determine specific provider practices associated with high provider efficiency in community emergency departments (EDs).

Methods

A mixed‐methods study design was utilized to identify key behaviors associated with efficiency. Stage 1 was a convenience sample of 16 participants (ED medical directors, nurses, advanced practice providers, and physicians) identified provider efficiency behaviors during semistructured interviews. Ninety‐nine behaviors were identified and distilled by a group of three ED clinicians into 18 themes. Stage 2 was an observational study of 35 providers was performed in four (30,000‐ to 55,000‐visit) community EDs during two 4‐hour periods and recorded in minute‐by‐minute observation logs. In Stage 3, each behavior or practice from Stage 1 was assigned a score within each observation period. Behaviors were tested for association with provider efficiency (relative value units/hour) using linear univariate generalized estimating equations with an identity link, clustered on ED site.

Results

Five ED provider practices were found to be positively associated with efficiency: average patient load, using name of team member, conversations with health care team, visits to patient rooms, and running the board. Two behaviors, “inefficiency practices,” demonstrated significant negative correlations: non–work‐related tasks and documentation on patients no longer in the ED.

Conclusions

Average patient load, running the board, conversations with team member, and using names of team members are associated with enhanced provider productivity. Identification of behaviors associated with efficiency can be utilized by medical directors, clinicians, and trainees to improve personal efficiency or counsel team members.

     

Interdisciplinary development and implementation of a dementia skills training program in a VA community living center: a pilot study

This pilot study investigates the usefulness of a dementia care training program developed by an interdisciplinary team to address problem behaviors associated with dementia. Staff members of a VA Community Living Center completed an 8-hour workshop covering fundamental knowledge about dementia and instruction in skills to use with patients through video, lecture, and role-plays. Measures on dementia knowledge and perceived self-efficacy were completed by staff members before and after the workshop. Results revealed increases in self-efficacy and knowledge, with particular gains in general knowledge of dementia and communicating with patients. Younger staff members scored higher on tests of knowledge at pre- and post-test, whereas staff members with more years of work experience rated their self-efficacy higher at post-test only. There was an associated decrease in assaultive behaviors by patients with dementia in the year this workshop was implemented. Results highlight the benefit of interdisciplinary collaboration in developing educational content and the value of providing staff training on managing dementia-related behaviors. Adjustments to this training program are discussed.     

Team care: beyond open and closed intensive care units

PURPOSE OF REVIEW: Evidence supporting dedicated intensivist staffing in intensive care units is growing. Despite clinical and economic benefits, medical staff politics and a shortage of intensivists impede the intensivist model. The purpose of this paper is to accelerate patient's exposure to the benefits of intensivists, and introduce team care in the intensive care unit. RECENT FINDINGS: The cost savings achieved through intensivist staffing range from $510,000 to $3.3 million. The intensivist model may only have been adopted by 4% of intensive care units. Barriers to implementing the model are shortage of intensivists, reimbursement for intensivists, and political will. Four attributes make the model ideal: physical presence, knowledge of critical care practice, coordination of team care, and unit management. It may be helpful to not label intensive care units as open or closed and consider team care, whereby hospitals seek to achieve the attributes of the model given their resources and culture. SUMMARY: Intensivists save lives and costs. By working toward team care, hospitals may achieve a successful intensivist model, and patients may realize the benefits of spending less for healthcare and living longer. To achieve this model, physician and hospital leaders must form a partnership.