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Enhancing teamwork across care provider levels: The manager of a medical-surgical unit has observed and had complaints about, lack of teamwork between the RN’s and the patient care techs (PCT’s). Your task is to propose a plan to enhance teamwork on the unit

nursingteamworkhealth care

1Ballangrud R, et al. BMJ Open 2020;10:e035432. doi:10.1136/bmjopen-2019-035432

Open access

Longitudinal team training programme
in a Norwegian surgical ward: a
qualitative study of nurses’ and
physicians’ experiences with
teamwork skills

Randi Ballangrud ,1 Karina Aase ,2 Anne Vifladt 1

To cite: Ballangrud R, Aase K,
Vifladt A. Longitudinal team
training programme in a
Norwegian surgical ward: a
qualitative study of nurses’ and
physicians’ experiences with
teamwork skills. BMJ Open
2020;10:e035432. doi:10.1136/
bmjopen-2019-035432

► Prepublication history and
additional material for this
paper are available online. To
view these files, please visit
the journal online (http:// dx. doi.
org/ 10. 1136/ bmjopen- 2019-
035432).

Received 31 October 2019
Revised 27 April 2020
Accepted 18 May 2020

1Department of Health Science
Gjøvik, Norwegian University of
Science and Technology, Gjøvik,
Norway
2Center for Resilience in
Healthcare (SHARE), University
of Stavanger, Stavanger, Norway

Correspondence to
Dr Randi Ballangrud;
randi. ballangrud@ ntnu. no

Original research

© Author(s) (or their
employer(s)) 2020. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
BMJ.

Strengths and limitations of this study

► In this study, the sample of both nursing staff and
physicians contributes to interprofessional experi-
ences in the implementation of a team training pro-
gramme in a surgical ward.

► The study intervention was based on an evidence-
based team training programme with a standardised
curriculum.

► A longitudinal design enables data collection on
three occasions.

► The sample size was small, leading to a relatively
limited number of participants in the focus group
interviews.

AbStrACt
Objectives Teamwork and interprofessional team training
are fundamental to ensuring the continuity of care and
high- quality outcomes for patients in a complex clinical
environment. Team Strategies and Tools to Enhance
Performance and Patient Safety (TeamSTEPPS) is an
evidence- based team training programme intended to
facilitate healthcare professionals’ teamwork skills. The
aim of this study is to describe healthcare professionals’
experiences with teamwork in a surgical ward before
and during the implementation of a longitudinal
interprofessional team training programme.
Design A qualitative descriptive study based on follow- up
focus group interviews.
Setting A combined gastrointestinal surgery and urology
ward at a hospital division in a Norwegian hospital trust.
Participants A convenience sample of 11 healthcare
professionals divided into three professionally based focus
groups comprising physicians (n=4), registered nurses
(n=4) and certified nursing assistants (n=3).
Interventions The TeamSTEPPS programme was
implemented in the surgical ward from May 2016 to June
2017. The team training programme included the three
phases: (1) assessment and planning, (2) training and
implementation and (3) sustainment.
results Before implementing the team training
programme, healthcare professionals were essentially
satisfied with the teamwork skills within the ward.
During the implementation of the programme, they
experienced that team training led to greater awareness
and knowledge of their common teamwork skills.
Improved teamwork skills were described in relation to a
more systematic interprofessional information exchange,
consciousness of leadership- balancing activities and
resources, the use of situational monitoring tools
and a shared understanding of accountability and
transparency.
Conclusions This study suggests that the team training
programme provides healthcare professionals with a
set of tools and terminology that promotes a common
understanding of teamwork, hence affecting behaviour
and communication in their daily clinical practice at the
surgical ward.
trial registration number ISRCTN13997367.

IntrODuCtIOn
Teamwork is fundamental to ensuring the
continuity of care and high- quality outcomes
for patients in a complex clinical environment,
necessitating training across professional
silos.1 2 Team training has been described as a
learning strategy in which a learner or group
of learners systematically acquire(s) team-
work knowledge, skills and abilities to impact
cognition, affect and behaviours of a team.3
Teamwork is found to positively affect clinical
performance.4

In hospitals, many adverse events are asso-
ciated connected to surgery.5–7 A system-
atic review by Johnston et al8 documented
that a delayed escalation of patient care
after surgical complications is associated
with higher mortality rates, identifying poor
communication, hierarchical barriers and
high workloads as causal factors. Previous
research has provided evidence for strategies
such as team training to improve the surgical
culture9 and have a positive effect on postop-
erative patient outcomes.10–12

Several team training programmes have
been developed in healthcare.13 In this paper,

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ISRCTN13997367

2 Ballangrud R, et al. BMJ Open 2020;10:e035432. doi:10.1136/bmjopen-2019-035432

Open access

we studied the implementation of the Team Strategies and
Tools to Enhance Performance and Patient Safety (Team-
STEPPS) in a surgical ward. TeamSTEPPS is a publicly
released, evidence- based programme based on teamwork
theory14 and change theory.15 The programme was devel-
oped by the Agency for Healthcare Research and Quality
in collaboration with the US Department of Defense and
was released in 2006.16 17 TeamSTEPPS, which is trans-
ferable to any healthcare setting, intends to facilitate
healthcare professionals’ teamwork by optimising team
structure and the team’s communication, leadership,
situation monitoring and mutual support skills. The basic
assumption of the programme is that these five teamwork
principles are critical for safe patient care.16

Systematic reviews have confirmed that team training
affects outcomes related to the team knowledge, atti-
tudes, behaviours of healthcare professionals3 18–20 and
results in improved quality.3 Furthermore, increased
confidence and motivation to apply learned teamwork
skills in daily practice have been experienced by health-
care professionals.21

Quantitative studies of the TeamSTEPPS programme
have confirmed improvements in teamwork and commu-
nication,22 23 patient safety culture,24–27 efficiency inpa-
tient care,24 25 28 complications and mortality,29 falls23
and frequency of wrong- site/side/person surgery.22
Most of the TeamSTEPPS studies are carried out in the
USA30 without any longitudinal follow- up, and there are
currently only a few qualitative studies18—for example,
in surgical and paediatric intensive care25 and cardiotho-
racic surgery telemetry.31 However, a need persists for
qualitative studies in surgical ward settings because the
team structure in wards is different from that in intensive
care unit (ICU) settings; physicians are not situated in the
ward for extended periods, thus restricting the possibili-
ties for interprofessional reflections.32 This study is a part
of a larger research project, comprising mainly substudies
with a quantitative design, to evaluate an interprofes-
sional team training intervention in a surgical ward.33 34
In this context, a qualitative study will provide in- depth
knowledge of healthcare professionals’ experiences with
learned teamwork skills in a longitudinal perspective.

We aimed to describe healthcare professionals’ experi-
ences with teamwork in a surgical ward before and during
the implementation of a longitudinal interprofessional
team training programme. The following research ques-
tion guided the study: how do healthcare professionals
experience teamwork skills communication, leadership,
situation monitoring and mutual support before and
during the implementation of an interprofessional team
training programme?

MethODS
Design
The study used a qualitative descriptive design35 based
on semistructured focus group interviews with healthcare
professionals at three- time intervals.

Setting
The study was carried out at a 20- bed combined gastro-
intestinal surgery and urology ward at a hospital divi-
sion (198 beds) in a Norwegian hospital trust. The
surgical ward was selected based on practical issues and
the management’s interest and motivation for improve-
ment initiatives after experiencing several patient safety
incidents. The study occurred from April 2016 to June
2017. At baseline (November 2015 to March 2016), the
ward statistics indicated an average bed occupancy rate
of 87%, a mean patient length- of- stay value of 3.46 days
and an admissions rate of 192.2 patients per month.
Moreover, the ward’s number of full- time positions was 13
physicians, 17.25 registered nurses (RNs), 4.95 certified
nursing assistants (CNAs), 1.0 head nurse and 1.0 clinical
nurse specialist.

The patient care was organised into two interprofes-
sional teams, where the primary members were RNs,
CNAs and physicians. The composition of the teams and
their duties were predetermined by a daily worklist for
the nursing staff, while the physicians had their worklist,
clarifying weekly duties such as surgery, polyclinic and
doctors’ rounds.

Sample
A convenience sample36 of 11 healthcare professionals
divided into three professionally based focus groups
comprising physicians (n=4), RNs (n=4) and CNAs (n=3)
were recruited from the surgical ward. The inclusion
criterion for participation in the study was that healthcare
professionals from the surgical ward had participated at a
minimum of 1 day of the interprofessional team training
programme (41 participants). The ward management
decided which professional groups participated in the
TeamSTEPPS training programme. A request for infor-
mation about the study and researchers was distributed
to all healthcare professionals, where 11 confirmed their
participation, thus constituting the study sample. The
sample comprised eight women and three men with
varying work experiences and employment within the
ward. To secure the participants’ anonymity, no specifica-
tion of their background is presented.

team training programme
The longitudinal interprofessional team training
programme was planned and implemented according to
the TeamSTEPPS- recommended ‘model of change’ and
was organised into three phases16 (see table 1 and box 1).
A research group initiated the programme as part of a
larger research project.34 Two nurses (one leader) and
two physicians (leaders) from the surgical ward had the
main responsibility for the training and implementation
of the programme. Before the training, the four health-
care professionals conducted the TeamSTEPPS V.2.0
Master Training Course and were certified as instructors.
A more detailed description of the programme can be
found in Aaberg et al.37

3Ballangrud R, et al. BMJ Open 2020;10:e035432. doi:10.1136/bmjopen-2019-035432

Open access

Table 1 Implementation of tools at phase 2 and phase 3 of the team training programme

Phase 2 Phase 3

2016 Tools Implementation arena 2017 Tools Implementation arena

May

Closed- loop
Communication

Exchange of critical
information

January

Debriefs
Leadership

Once a week—
manager with nursing
staff

Task Assistance
Mutual support

Distribution of workload

June ISBAR
Communication

Communicating critical
information

February STEP
Situation monitoring

Updated in electronic
care plan

August Briefs
Leadership

Start of every shift March Two- Challenge Rule
Mutual support

When an initial
assertive statement is
ignored

September Huddles
Leadership

At patient safety
whiteboard meetings

May I- PASS
Communication

Handoffs with focus on
patient safety risks

October Cross- monitoring
Situation monitoring

Double control by
intravenous medication
administration

I- PASS, illness severity, patient summary, action list, situation awareness and contingency planning; ISBAR, introduction, situation,
background, assessment, recommendation; STEP, status of the patient, team members, environment, progress towards the goal.

box 1 team training programme based on teamStePPS

Phase 1: set the stage and decide what to do—assessment and
planning (January 2016–April 2016)

► Site assessment.
► A lesson about teamwork in relation to promoting patient safety was
conducted with all nurses and physicians to create an awareness of
the need for improvement.

► A training and implementation plan was developed.
Phase 2: making it happen—training and implementation (May
2016–December 2016)

► One day of interprofessional team training in a simulation centre
was completed for all healthcare professionals (n=41) in the surgi-
cal ward, comprising 6 hours of classroom training (lectures, videos,
role plays and discussions) and 2 hours of high- fidelity simulation.

► A change team with members from all ward professions and a for-
mer patient was assigned.

► An action plan was established, based on identified patient safety
issues in the ward.

► The TeamSTEPPS tool was systematically implemented every month
(see (table 1)).

Phase 3: making it stick—sustainment (January 2017–June 2017)
► The initiatives from the action plan were coached, monitored and
integrated.

► Implementation of a monthly TeamSTEPPS tools continued.
► Small victories were celebrated.
► TeamSTEPPS refresher courses were held after four (nurses and
physicians) and 11 months (nurses).

TeamSTEPPS, Team Strategies and Tools to Enhance Performance and Patient
Safety.

Data collection
Ten focus group interviews of healthcare professionals
were conducted before the team training implementation

(baseline=T0), with follow- up interviews after 6 months
(T1) and 12 months (T2) (see figure 1).

All the interviews occurred in a meeting room at
the hospital during the daytime. A pilot interview was
conducted to validate the thematic interview guides
developed from a literature review on teamwork (online
supplementary files 1 and 2). The interviews were
conducted as a dialogue and started with a clarification of
the study aim. The thematic interview guides, including
the four teamwork skills at T1 and T2, were used to
ensure that all themes were explored during each focus
group interview. The participants were encouraged to
complete an open collective activity with a reflection on
common experiences.38 The same questions were posed
to all focus groups, and follow- up questions were used to
encourage the participants to elaborate and/or clarify
their responses.39 One moderator and one observer (who
made field notes) were responsible for conducting the
interviews, with the third author (AV) as a moderator at
T0 and the first author (RB) as a moderator at T1 and T2.
At T0, the interview referred to generic questions about
teamwork at the ward (see online supplementary file 1);
at T1 and T2, the interview questions referred to learned
teamwork skills based on the TeamSTEPPS framework
(see online supplementary file 2). The field notes were
approved by the participants after the interview. The
interviews lasted from 25 to 60 min (mean=33 min).
All the interviews were digitally recorded, transcribed
verbatim and anonymised before the analysis.

Data analysis
Based on the aim and research question of our study
focusing on healthcare professionals’ experiences with
teamwork skills during a team training programme, a

https://dx.doi.org/10.1136/bmjopen-2019-035432

4 Ballangrud R, et al. BMJ Open 2020;10:e035432. doi:10.1136/bmjopen-2019-035432

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T0
Interview, April 2016

Profession (focus groups 1–3)

T1
Interview follow up after
six months, November 2016

Profession (focus groups 4–7)

T2
Interview follow up after
12 months, June 2017

Profession (focus groups 8–10)

RNs (n=4)
CNAs (n=2)
Physicians (n=3)

RNs (n=3)
CNAs (n=2)
Physicians (n=2)
Physicians (n=2)

RNs (n=3)
CNAs (n=2)
Physicians (n=1)

Start of team training programme, May 2016

Figure 1 An overview of participants, and times of the interviews in relation to the implementation of a team- training

programme; n=11 healthcare professionals (four physicians, four RNs and three CNAs). CNA, certified nursing assistant; RN,
registered nurse.

Table 2 Description of the four TeamSTEPPS teamwork skills

Communication Structured process by which information is clearly and accurately exchanged among team members

Leadership Ability to maximise the activities of team members by ensuring that team actions are understood, changes in
information are shared and team members have the necessary recourses

Situation monitoring Process of actively scanning and assessing situational elements to gain information or understanding, or to
maintain awareness to support team functioning

Mutual support Ability to anticipate and support team members’ needs through accurate knowledge about their
responsibilities and workload

Agency for Healthcare Research and Quality. TeamSTEPPS V.2.0: Core Curriculum.16

TeamSTEPPS, Team Strategies and Tools to Enhance Performance and Patient Safety.

deductive manifest content analysis approach grounded
on Elo and Kyngäs40 was used. The data were analysed
according to the TeamSTEPPS framework,41 42 focusing
on the four teamwork skills of communication, lead-
ership, situation monitoring and mutual support. The
description of the four teamwork skills is shown in table 2.

The analysis process was organised according to three
phases: preparation, organising and reporting. The first
(RB) and third (AV) authors conducted the first two
phases with input from the second author (KA), while all
three authors conducted the third phase. In the preparation
phase, each interview was defined as one unit of analysis,
and data from T0, T1 and T2 were analysed separately. All
the interviews were read several times by all three authors
to become familiar with the data, and, guided by the aim
and research questions, the researchers obtained intimate
knowledge of the participants’ experiences with teamwork
skills. In the organisation phase, the authors established a
structured analysis matrix, with columns representing
the categories of communication, leadership, situation
monitoring and mutual support. Based on the concep-
tual description of each TeamSTEPPS teamwork skill in
the TeamSTEPPS programme (see table 2),16 all the data
were reviewed for content and coded according to the
four teamwork categories (without using any software

tool), first individually by RB and AV, and then together
by all three authors until agreement was reached. Exam-
ples from the codebook at T1 are shown in table 3. The
matrix revealed 514 codes representing the four team-
work categories. In the reporting phase, the results were
described using the contents of each of the four team-
work categories. Quotations were used to enhance and
illuminate the categories.43 To help secure a presentation
of results representing the information provided by the
participants, continuous discussion among the authors
was prominent throughout the reporting phase. Finally,
the results were reported according to the Consolidated
Criteria for Reporting Qualitative Research (online
supplementary file 3).44

Patient and public involvement
Patients or the public were not involved in the design,
conduct, reporting or dissemination plans of our research.

reSultS
teamwork at t0
The healthcare professionals’ experiences of the four
teamwork skills in the surgical ward before the team
training programme (T0) are described in table 4.

https://dx.doi.org/10.1136/bmjopen-2019-035432

5Ballangrud R, et al. BMJ Open 2020;10:e035432. doi:10.1136/bmjopen-2019-035432

Open access

Table 3 Codebook examples from the qualitative deductive content analysis at T1

Communication Leadership Situation monitoring Mutual support

T1:RN,24. Everyone
participates using a closed
loop.

T1:RN,94. We allocate the
tasks now so that they are
distributed more evenly.

T1:RN,80. We have become
more vigilant about medication
administration.

T1:RN,35. When you know the
purpose, you have a greater
understanding for reporting a
second time concern.

T1:CNA,5. On the classroom
training day, we learnt to repeat
messages—for example, when
we take the phone—which is
already done.

T1:CNA,36. The ward
management is aware that
the whiteboard meetings
will take place.

T1:CNA,30. The most
important thing about the
whiteboard meetings is that
there is a proper review of
patients after the doctor’s
rounds.

T1:CNA,56. It is not so easy to
say so if there is something that
we disagree about, compared
with when there is something
positive.

T1:Ph1,26. Seemed like
the nurses were confident
about how to present patient
information to us.

T1:Ph2,84. If one is to
think we are a team, it is
natural that the physician
who does the round is the
leader.

T1:Ph1,69. Whiteboard
meetings generate awareness
about—for example, safety
routines, nutrition, medication
administration, etc—that is,
such things that are good to
check.

T1:Ph,43. It is now easier to
ask each other since we know
each other better after being in
classroom training together.

CNA, certified nursing assistant; Ph, physician; RN, registered nurse.

teamwork during the 12-month (t1–t2) interprofessional
team training programme
A summary of healthcare professionals’ experiences
with the four teamwork skills during the 12- month team
training programme is described in table 5.

Communication, t1–t2
The RNs experienced a common set of tools that promote
patient safety. Everyone emphasised the ‘closed loop’ tool
as important to ensure a common understanding within
the team. Using the tool, the RNs detected misunder-
standings that could have caused consequences for the
patient. Both the CNAs and RNs emphasised that, after
the 12- month implementation of the team programme,
they used the ‘closed loop’. They perceived the tool as
important, simple to use and promoting patient safety, as
exemplified by a CNA:

If there is a phone call and you receive a message then
you repeat the message … to make sure you have got
it right—don’t you? (T2:CNA,2)

The RNs found it valuable to have a common under-
standing of communication skills with physicians at the
surgical ward. However, they experienced that physicians
from other wards, who were not included in the Team-
STEPPS programme, expressed the feeling that the RNs
were criticising them when using the ‘closed loop’.

During the implementation period, both the physicians
and CNAs experienced the RNs as being more confident
in their information exchange and found ‘introduction,
situation, background, assessment, recommendation
(ISBAR)’ useful when communicating important or crit-
ical information over the phone. The RNs experienced
the use of ‘ISBAR’ as somewhat challenging but easier
to use when they had enough time. The physicians high-
lighted that their medical education taught them how to

provide information systematically. However, they became
more aware of systematic communication and repeating
messages:

Well, I think everyone … everyone involved has re-
flected … and raised one’s consciousness regarding
it [communication] to a greater extent than if they
didn’t attend the course. (T2:Ph,11)

With ‘ISBAR’, it had become more natural for the RNs
to take an active part in patient treatment. They referred
to common, established expectations toward more active
participation, with ‘ISBAR’ focusing on their perception
of the problem and how to handle it. One RN said:

When we call about a deteriorating patient … I pre-
viously thought I shouldn’t mention anything regard-
ing my ideas on the causes of deterioration. I always
thought that was the physician’s task. (T2:RN,13)

The ‘handoff’ tools for information exchange during
shifts had been introduced late and were not properly
integrated at the ward. One RN said:

Well, then at least you will need sufficient time to re-
flect before starting to use them [tools]… and that is
not always the case, right. (T2:RN,45)

Even though it is an easy … an easy tool, I actually
think it is one of the hardest as well. (T2:RN,46)

leadership, t1–t2
The RNs experienced that TeamSTEPPS had led to an
increased awareness in using ‘huddling’ and ‘briefing’
at the patient safety whiteboard meetings. One RN
explained:

We use huddling at the patient safety whiteboard
meetings regarding the redistribution of tasks if

6 Ballangrud R, et al. BMJ Open 2020;10:e035432. doi:10.1136/bmjopen-2019-035432

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Table 4 Teamwork skills at T0

Teamwork skills
categories

Communication All healthcare professionals were mostly satisfied with the information exchange within the ward, with the
nurse team leader possessing a central position. A busy schedule allowed the RNs, who often had patient
responsibility within both teams, to acquire patient information in different ways, from participation in regular
team meetings to ad- hoc meetings with the team leaders. The CNAs appreciated the ‘quiet handover’ used
between shifts. When calling up the physicians on duty, the RNs often checked the phone list ahead of the
phone call to be prepared, indicating that some physicians needed to have more background information
than others. The physicians also emphasised the importance of proper and relevant information from the
RNs who can be trusted.

Leadership The two core teams each had a team leader throughout the week, allowing the team leader to become
better acquainted with a patient’s medical history and thereby increasing continuity and simplifying the
hospital discharge. Not all of the RNs enjoyed being team leaders due to a heavy workload; however, the
physicians were satisfied with the arrangement.

Situation
monitoring

The physicians became familiar with the patients during rounds and through the patient’s medical record,
mostly discussing patient- related issues in physicians’ meetings. Similarly, the RNs discussed issues related
to patients’ care in nurse meetings, although this may also have resulted in contact with the physicians.
Both RNs and CNAs had an active role in the observation of the patients and updating each patient’s
care plan, and they were encouraged to stay bedside during the rounds. The Modified Early Warning
Score (MEWS)* was recently applied, and the physicians were pleased with the new routines, which was
highlighted as an excellent tool to quickly determine the degree of illness of a patient. Moreover, the ward
was in the initial phase of using a patient safety whiteboard; thus, these meetings did not work optimally
with a frequent absence of physicians.

Mutual support The RNs and CNAs stated that they were flexible in helping each other in the event of an uneven distribution
of work, both within the team and between the teams. However, the teamwork was dependent on
openness and that team members spoke out when they needed help. They felt listened to and respected
by the physicians. All three healthcare professionals groups stated that knowing each other and having
fun together strengthened a good working environment and good teamwork. The physicians highlighted
that, for the best interest of the patient, good teamwork requires nurses with medical knowledge, clinical
experience and continuity with the patient. Nonetheless, the RNs experienced that they did not always have
the expected response from the physicians, and the physicians stressed that a large workload requires
prioritisation of multiple issues at one time, which may affect the teamwork. According to the RNs, this
rarely causes conflicts among healthcare professionals in the ward. Nevertheless, there have been real
conflicts, and some have been perceived as a personal attack.

*MEWS is a tool for bedside evaluation of the systolic blood pressure, pulse rate, respiratory rate, temperature and Alert, Reacting to Voice,
Reacting to Pain, Unresponsive score.57

CNA, certified nursing assistant; RN, registered nurse.

anyone feels they have too much work, while others
have available capacity. (T2:RN,58)

The redistribution of work tasks resulted in a more
even workload between the two core teams at the ward.

At T1, the mid- day nurse meeting was led by the RN
team leaders, whereas the physicians initially led the
interprofessional patient safety whiteboard meetings.
The RNs experienced it as natural that the physicians
led the meetings whenever they were present. However,
at T2, the mid- day nurse meeting was replaced with the
interprofessional patient safety whiteboard meeting, led
by the RN team leader. The physicians could not always
attend the patient safety whiteboard meeting due to activ-
ities in the operating theatre, being called for and so on.
While whiteboard meetings occurred daily, the weekly
‘debriefing’ occurred on Fridays. The ward head nurse
usually led the ‘debriefing’, which was experienced as
useful, as exemplified by a CNA:

It is good to talk things through, expressing issues
that are on your mind when it has been a busy week
… also experiencing that debriefing can be funda-
mental for change. (T3:CNA,30)

The physicians were more uncertain whether the team
training programme had led to an increased awareness of
team leadership.

Situation monitoring, t1–t2
The use of the term ‘situation monitoring’ was new for
healthcare professionals. The RNs realised that they had
always monitored the work system without being aware
of the term. By using the tools, they detected patient
safety incidents that could have resulted in unnecessary
harm to the patients. Cross- monitoring of the intravenous
medication administration had been implemented. The
RNs experienced the use of situation monitoring skills
depended on their role in the team. As team leaders, they

7Ballangrud R, et al. BMJ Open 2020;10:e035432. doi:10.1136/bmjopen-2019-035432

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Table 5 Experiences with teamwork skills at T1 and T2 of the team training programme

Categories T1 (6 months) T2 (12 months)

Communication Increased awareness in using the closed loop
and ISBAR tools.

*
———————————————————→

Challenges with using ISBAR when
communicating critical information (RNs).

RNs are more confident in information exchange using
ISBAR. ISBAR forms a basis for a more active role for
RNs in decision- making.

Challenges still exist when using ISBAR during busy
shifts.

The included tools are seen as a common
initiative to promote patient safety.

———————————————————→

Misunderstandings in work practice are discovered
when using the tools.

The tools provide information in a more systematic
manner.

Handoff not properly incorporated.

Leadership Distribution of work tasks using huddling. ———————————————————→
RN team leader runs the mid- day nurse
meeting.

Mid- day nurse meeting replaced with patient safety
whiteboard meeting.

Physician runs the interprofessional patient
safety whiteboard meeting when present,
otherwise an RN.

RN runs the interprofessional patient safety whiteboard
meetings.

Head nurse runs the Friday debriefing, evaluating the
weekly activities.

Situation monitoring Double control in intravenous medication
administration using cross- monitoring.

———————————————————→

Risk assessment at whiteboard meetings
provides awareness of new and/or important
patient issues.

Risk assessment at interprofessional patient safety
whiteboard meetings established on weekdays,
challenges on weekends.

Nursing plans less prioritised due to patient
safety whiteboard meetings.

———————————————————→

MEWS prioritised. MEWS a well- established routine.

Mutual support Transparency and openness across the
healthcare team.

———————————————————→

Legitimate to express safety concerns. ———————————————————→
Use of the Two- Challenge Rule to resolve
disagreements.

———————————————————→

Increased awareness of speaking up for the patients.

Increased awareness of giving and receiving feedback.

*The arrow expresses continuity in healthcare professionals’ experiences throughout T1 and T2.
CNA, certified nursing assistant; ISBAR, introduction, situation, background, assessment, recommendation; MEWS, Modified Early Warning
Score; RN, registered nurse.

had to scan what was going on at the ward; however, if
they were situated inside the patient room, they lost sight
of other ongoing issues.

Six months into the team training programme, health-
care professionals experienced a better functioning of
the patient safety whiteboard meetings, though still not
optimal because physicians did not always attend. After
12 months, everyone experienced the meeting as a useful
and well- established arena to monitor patient risks. They

also experienced that the meeting created an awareness
of tasks that needed attention, as described by a physician:

Yes, fall prevention, nutrition, medication reconcili-
ation. Well, that’s the type of issue that … it’s con-
venient to check, reminding us of issues that need
attention. (T1:Ph,69)

Despite the benefit of the whiteboard meetings, they
were not prioritised on busy shifts during the weekends.

8 Ballangrud R, et al. BMJ Open 2020;10:e035432. doi:10.1136/bmjopen-2019-035432

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Both the RNs and CNAs were responsible for updating
the patient safety whiteboard according to their patients’
needs and realised that the increased whiteboard focus
negatively affected the updating of the nursing plans.

During the team training programme, the ‘Modified
Early Warning Score (MEWS)’ became a well- established
and systematic routine appreciated by all healthcare
professionals. Nevertheless, the physicians experienced
that some nurses did not relate the ‘MEWS’ measure-
ments to the patient’s condition, only using ‘MEWS’ as
a recipe. Some experienced that the RNs called them
without getting into the patient’s anamnesis from the
medical record seen as their common information
exchange system. It was expected that both RNs and
CNAs scored their patients with ‘MEWS’ and exchanged
the results with the team leader. They now measured
the patient’s pulse and blood pressure more frequently,
although it was described that the parameters might be
overlooked, as pointed out by one CNA:

Well, it is worth mentioning regarding MEWS that
people tend to forget to measure the pulse them-
selves. They see the number and then refer to this
… without acknowledging that the pulse can be as
irregular and deviating as ever. (T2:CNA,47)

Mutual support, t1–t2
The RNs perceived mutual support to the teamwork skill
creating the most influential changes at the ward, also
considered the most effective to implement. At T1, RNs
experienced increased transparency and openness across
the healthcare team. Colleagues raised problems more
directly. It became more legitimate to express concerns
and speak up because the contents could be addressed
in relation to the tools and strategies of the training
programme. With a common understanding in place,
it was easier to use a tool such as the ‘Two- Challenge
Rule’. A physician referred to an episode, where the RN
disagreed with him and used the tool:

There was a patient with … urine retention with
300 mL of residual urine and you are not supposed
to send them home without a catheter … but on that
occasion I meant that we could do so. And she [RN]
was absolutely right in her judgment … there are
routines for not having that much [residual urine],
and since I thought it was right I tried to explain it.
(T1:Ph,61)

Moreover:

It was, of course, ok, she did what she was supposed to
do and it is commendable that they raise it, that they
are not afraid of voicing it. (T1:Ph,62)

The physicians emphasised that it became easier to
collaborate on patient treatment with mutual and open
communication, and they felt that the team programme
had impacted this. At T2, the ‘Two- Challenge Rule’ was

used frequently, a strategy they probably used prior to the
programme, but as an RN expressed it:

Yes we did it [open communication, Two- Challenge
Rule] … it was just that we did not have a notion for
it. (T2:RN,40)

Hence, increased awareness of using different mutual
support tools had been created:

You don’t accept the response you are given; you
rather rephrase the question once or twice if neces-
sary. (T2:RN,102)

Both the RNs and CNAs had become more aware of
the importance of feedback. They evaluated the tools as
useful when adverse events occurred and, in that context,
experienced a high degree of support across the inter-
professional team. They experienced colleagues being
less concerned with raising issues through feedback,
and, according to RNs, the ‘go to the leader’ mentality
when dissatisfied was less prominent. The RNs had also
seen inexperienced RNs who now dared to speak up
for the patient. However, they still felt that healthcare
professionals held back on different occasions, implying
a continued room for improvement within giving and
receiving feedback.

DISCuSSIOn
We aimed to describe healthcare professionals’ experi-
ences with teamwork in a surgical ward before and during
the implementation of a longitudinal interprofessional
team training programme. The results described that RNs,
CNAs and physicians were highly satisfied with the team-
work at the ward before the team training programme.
Nevertheless, they experienced that the implementation
of the programme, where they were trained together, led
to greater awareness and knowledge of their common
teamwork skills. Changes were described related to more
systematic information exchange, increased conscious-
ness of team leadership balancing activities and resources,
increased use of situation monitoring tools and a common
understanding of accountability and transparency.

Communication: towards a systematic information exchange
When RNs used the communication tool ‘ISBAR’, the
physicians experienced a more systematic exchange
of patient information, which was highly appreciated.
The RNs experiencing challenges using the tool in the
first phase and eventually became more confident.
This finding is in accordance with results from a study
in surgical wards, where both nurses and physicians
perceived ‘ISBAR’ as effective in obtaining a structure of
the contents of patient reports.45 Nurses and physicians
traditionally communicate using different styles appro-
priate to the needs and processes of their respective
professions.46 47 This gap may be bridged using ‘ISBAR’,
establishing a common communication style. Hierar-
chical culture has been experienced by nurses as having

9Ballangrud R, et al. BMJ Open 2020;10:e035432. doi:10.1136/bmjopen-2019-035432

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a negative effect on interactions with some physicians.31
According to De Meester et al,48 the use of ‘ISBAR’ may
flatten the hierarchical structure by nurses experiencing
being empowered, thereby resulting in more effective
communication channels. The RNs in our study referred
to a positive change with expectations towards more active
participation in patient decision- making. Open commu-
nication with a common language of how to present key
patient information can prevent misunderstandings and
communication failures.49 Interprofessional teamwork
is generally found to motivate and empower staff when
team members feel their roles are acknowledged.50

leadership: balancing activities and resources
Leadership was seen as an essential teamwork skill to
increase the continuity of patient care, with an even distri-
bution of work tasks and debriefing as essential activities.
According to Salas et al,14 team leadership coordinates
and organises team members’ activities. Considering that
the team leader possesses knowledge of team resources,51
they have the opportunity to ‘balance the workload within
the team’.16 In this study, the redistribution of work tasks
was completed at the daily patient safety whiteboard
meeting led by the RN team leader. At these meetings, the
use of the tool ‘huddling’ was implemented and found
useful when balancing work tasks within and between
the two ward teams—the intention using huddles.16 The
leader’s overview of team activities is essential, with the
weekly debriefing meeting described as ‘fundamental for
change’ due to the opportunity for healthcare profes-
sionals to share their experiences related to patient care as
a basis for improvement in procedures or work routines.

Situation monitoring: towards a conscious use of tools and
interprofessional meetings
Our study confirmed that using the term ‘situation moni-
toring’ was new for healthcare professionals at the surgical
ward, although they realised they had previously used the
skill unconsciously. According to Benner,52 knowledge
development in healthcare consists of spreading practical
knowledge and the mapping of existing practical knowl-
edge developed through clinical experience, to which the
team training programme may have contributed. RNs,
CNAs and physicians all experienced increased attention
towards situation monitoring skills throughout the use
of MEWS, as well as at the daily interprofessional patient
safety whiteboard meetings established during the team
training programme period. These meetings were expe-
rienced as useful opportunities to monitor patients and
create an awareness of necessary tasks. This finding is in
accordance with Sehgal et al,53 where nurses were seen
as responsible for accurate and updated information
on whiteboards, whereas the goals for the day should
be created jointly by nurses and physicians. The physi-
cians in the current study appreciated that the nursing
staff referred to MEWS when calling them. Early warning
scores are known to have a good prognostic value for
patient deterioration and have been shown to improve

patient outcomes, partly because they facilitate communi-
cation among healthcare professionals.54 Like the physi-
cians, the nurses also saw the importance of gathering the
MEWS but also emphasising the importance of using their
clinical eye and mind. In their integrative review, Massey
et al55 found that assessing and knowing the patient, nurse
education and the use of specialised equipment were all
factors with an impact on ward nurses’ ability to recognise
patient deterioration.

Mutual support: towards accountability and transparency
In our study, mutual support was considered the most
effective teamwork skill to implement and, according to
the RNs, contributed to the most comprehensive positive
change at the ward during the team training programme.
This was despite healthcare professionals referring to a
ward culture with open communication, including before
the training programme. Mayer et al25 found that, by using
pre- implementation and post implementation interviews
of staff in surgical ICUs, the informants described an
overall improved mutual support with a more positive
team morale across physicians and nurses post imple-
mentation. In a qualitative study conducted by Baik and
Zierler,31 the nurses reported improved changes in inter-
professional relationships and being more satisfied with
their work because they felt included as a member of
an interprofessional team training intervention. In our
study, both physicians and nurses experienced that when
having a common understanding, it was easier to use tools
such as the ‘Two- Challenge Rule’. Both RNs and CNAs
described that they had become more aware of giving
each other feedback. When adverse events occurred,
they experienced a high degree of support across the
interprofessional team, a situation that is in accordance
with Weller et al,56 who interviewed a surgical team in
an operating room and described a positive change in
information sharing and improved confidence, as well
as a greater awareness of the other team members and
working environment, after conducting a simulation-
based team training programme.

limitations
There are several limitations in our study that need to
be recognised. The results may be influenced by the
relatively limited number of participants in each of the
focus group interviews and a possible bias in the sample
of participants based on possible positive perceptions of
teamwork at the surgical ward. The study is not suitable
for generalisation; however, the results based on our
qualitative design provide a deeper understanding of the
health professionals’ experiences with learned teamwork
skills that may be relevant at other hospital wards. Due to
time pressure and workload in their daily practice at the
surgical ward, the healthcare professionals had to repeat-
edly change their interview times, which may have affected
the results. Two groups of two physicians participated in
the interviews after 6 months, whereas only one physi-
cian had the opportunity to participate after 12 months.

10 Ballangrud R, et al. BMJ Open 2020;10:e035432. doi:10.1136/bmjopen-2019-035432

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A larger group of physicians might have provided other
experiences with the teamwork skills that may also impact
the results because mostly the nursing staff attended the
refresher courses. The results may also be influenced
by the patient safety initiatives recently initiated at the
ward ahead of the team training programme, such as the
MEWS and patient safety whiteboard meetings.

COnCluSIOn
Our study suggests that, during a team training
programme, healthcare professionals were provided with
a set of tools and terminology that promoted a common
understanding of teamwork, hence affecting behaviour
and communication in their daily clinical practice at
a surgical ward. The findings contribute to the qual-
itative evidence base of the implementation of team
training programmes. More specifically, the study docu-
mented the role of a systematic information exchange,
a consciousness of leadership and situation monitoring
skills and the importance of creating a culture of account-
ability and transparency in a surgical ward. Further
research should study the effect of the implementation
of the TeamSTEPPS programme in hospitals, including
various departments. Moreover, a study on the long- term
sustainability of team training programmes on healthcare
professionals’ behaviour is necessary.

Contributors RB, KA and AV were responsible for the study design. RB and AV
performed the data collection. RB, KA and AV contributed to the analysis of the
data, drafting of the manuscript, critical revision of the manuscript for important
intellectual content and final approval of the version to be published. All the authors
read and approved the final manuscript.

Funding This study was supported by the Norwegian Nurses Organisation
(15/0018), the Norwegian University of Science and Technology in Gjøvik and the
University of Stavanger.

Competing interests None declared.

Patient consent for publication Not required.

ethics approval The study was approved by the Norwegian Center for Research
Data (Ref. 46872) and permission was given by the head administration in the
participating hospitals. The Committee for Medical and Health Research Ethics of
South- East Norway reviewed the study (Ref. 2016/78) and responded that approval
was not necessary according to Norwegian law, since the study did not involve
patients. Information and an invitation to participate in the study were given to
healthcare professionals in written and verbal forms, referring to the principle of
autonomy addressed by confidentiality and voluntariness. Written consent was
obtained from the healthcare professionals who agreed to participate. The study
was conducted in accordance with the principles of the Declaration of Helsinki.

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement No data are available. No additional unpublished data
are available from this study.

Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non- commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.

OrCID iDs
Randi Ballangrud http:// orcid. org/ 0000- 0003- 0403- 0509
Karina Aase http:// orcid. org/ 0000- 0002- 5363- 5152
Anne Vifladt http:// orcid. org/ 0000- 0001- 6594- 9725

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Longitudinal team training programme in a Norwegian surgical ward: a qualitative study of nurses’ and physicians’ experiences with teamwork skills

Abstract

Introduction

Methods

Design

Setting

Sample

Team training programme

Data collection

Data analysis

Patient and public involvement

Results

Teamwork at T0

Teamwork during the 12-month (T1–T2) interprofessional team training programme

Communication, T1–T2

Leadership, T1–T2

Situation monitoring, T1–T2

Mutual support, T1–T2

Discussion

Communication: towards a systematic information exchange

Leadership: balancing activities and resources

Situation monitoring: towards a conscious use of tools and interprofessional meetings

Mutual support: towards accountability and transparency

Limitations

Conclusion

References

Nursing Inquiry. 2021;00:e12413. wileyonlinelibrary.com/journal/nin | 1 of 10
https://doi.org/10.1111/nin.12413

1 | INTRODUC TION

Global nursing and healthcare workforce shortages, increased de-
mands on healthcare systems and growing healthcare expenditure
have resulted in a focus on the development of strategies to pro-
vide cost- effective health care (All- Party Parliamentary Group on
Global Health (APPG), 2016; National Health and Hospital Reform
Commission (NHHRC), 2009). As part of these strategies, skill mix
and nurse staffing are manipulated to reduce costs and provide qual-
ity care to patients (Aiken et al., 2013; Jacob et al., 2015; NHHRC,
2009). Adding to this, the COVID 19 pandemic has placed further
strain on the healthcare system resulting in the need to build surge
workforce capacity to meet the needs of patients (Al Mutair et al.,
2020; Marshall et al., 2020). Healthcare organisations have been
required to reframe the delivery of patient care examining options
to augment and extend the nursing and healthcare workforce. A

common strategy is a tiered healthcare team approach to patient
care delivery based on the idea of experienced staff supervising
less experienced or lower trained staff members working together
to meet the patients’ needs (Al Mutair et al., 2020; Marshall et al.,
2020). This may occur in situations where tasks traditionally per-
formed by one worker are shifted to another worker (APPG, 2016).

Prior to the pandemic, pressures on healthcare systems interna-
tionally had increased the reliance on the use of unregulated nursing
assistant (NA) roles in the acute hospital setting (Aiken et al., 2016;
Blay & Roche, 2020; Duffield et al., 2014; Kalisch, 2011). To meet
pandemic surge workforce demands, healthcare teams may be addi-
tionally augmented with reassigned or redeployed staff with trans-
ferable skills, healthcare staff re- entering the hospital workforce,
final year students in nursing, medical and allied health courses and
NA roles (Al Mutair et al., 2020). It is imperative when working in
the multi- skilled/ multi- tiered nursing workforce environment that

Received: 8 April 2020 | Revised: 3 March 2021 | Accepted: 12 March 2021
DOI: 10.1111/nin.12413

F E A T U R E A R T I C L E

Transparent teamwork: The practice of supervision and
delegation within the multi- tiered nursing team

Felicity Ann Walker1,2 | Madeleine Ball2,3 | Sonja Cleary2 | Heather Pisani2

1Faculty of Health, Southern Cross
University, Bilinga, QLD, Australia
2School of Health & Biomedical Sciences,
RMIT University, Melbourne, Vic.,
Australia
3School of Health Sciences, University of
Tasmania, Melbourne, Vic., Australia

Correspondence
Felicity Walker, Faculty of Health,
Southern Cross University, Gold Coast
Campus, Southern Cross Drive, Bilinga,
Queensland 4225, Australia
Email: felicity.walker@scu.edu.au

Funding information
Australian Government Research Training
Program Scholarship

Abstract
Supervision and delegation are important leadership skills that nurses require when
practising within the multi- tiered nursing team. In response to increasing demands
globally on healthcare systems, Nursing Assistants are becoming more prevalent mem-
bers of the nursing workforce in the acute care setting. An exploratory descriptive re-
search design was used to examine supervision and delegation of Nursing Assistants
in an acute hospital setting in Victoria, Australia. It was found that supervision and
delegation in the context of a multi- tier nursing team required a complex assessment
and decision- making process which was influenced by multiple factors. This research
promotes developing transparent nursing practices and mutual understanding in the
multi- tier nursing team to facilitate effective supervision and delegation based on in-
formed decision- making and culture of openness and trust. Pre- registration education
and continuing education and support for nurses are important to build transparent
supervision and delegation practices and teamwork, empowering the nursing team to
practice to their full scope of practice to provide high- quality patient care.

K E Y W O R D S
accountability, delegation, leadership, nurse, nursing assistant, supervision, transparency

www.wileyonlinelibrary.com/journal/nin

mailto:

https://orcid.org/0000-0001-7576-1937

mailto:felicity.walker@scu.edu.au

http://crossmark.crossref.org/dialog/?doi=10.1111%2Fnin.12413&domain=pdf&date_stamp=2021-04-22

2 of 10 | WALKER Et AL.

each team member is cognisant of their roles, responsibilities and
capabilities and that appropriate delegation and supervision prac-
tices are in place to ensure the quality and safety of patient care.
This research aims to contribute to nursing practice through exam-
ining supervision and delegation practices occurring in a multi- tiered
nursing team consisting of Registered Nurses (RNs), Enrolled Nurses
(ENs) and NA in an acute care setting in Victoria, Australia.

This research focuses on the question of how supervision and
delegation of a NA position are practised in a multi- tier nursing team.
In the situation, researched NAs were introduced to the acute hospi-
tal setting, to enhance the patient experience, assist with the nurses’
workload allowing them to work up to their full scope and improve
retention of nursing staff at the research setting. The NA position
was additional to the mandated 1:4 nurse/ patient ratios and was
used to supplement the nursing workforce. NA attended to basic
care duties including patient hygiene, mobilisation, specialling at- risk
patients and general duties including restocking of cupboards and
checking of equipment. The NA was required to practice under the
supervision and delegation of the RN at all times.

Delegation and supervision are important leadership skills for
effective nursing care and teamwork. When delegating to and su-
pervising another worker, nurses need to use their critical thinking
skills to make an informed decision on the appropriate course of
action to maintain safe and quality patient care (Bittner & Gravlin,
2009; Quallich, 2005; Standing & Anthony, 2008; Weydt, 2010). The
nurse must use their assessment skills and determine whether a task
is appropriate for delegation and the required level of supervision
by examining the patient, the context and environment, as well as
the skill level/ qualification level needed for the task. They also need
to consider the competency and skill level of the person they are
delegating to, as individuals have different capabilities and supervi-
sion needs independent of role title. Second to this, the nurse must
establish whether the person also has the capacity and resources
to be able to attend to the task, taking into consideration the wider
context and ward needs (All- Party Parliamentary Group on Global
Health (APPG), 2016; Quallich, 2005; Weydt, 2010).

Nurses need to be aware of their accountability and responsi-
bilities when delegating and supervising others, remembering that
they retain accountability for their decision to delegate and for
monitoring outcomes (Nurisng & Midwifery Council, 2018; Nursing
and Midwifery Board of Australia (NMBA), 2007). The delegating
nurse is responsible for making sure the delegated task is completed
successfully and within a reasonable time frame, with feedback
provided to the delegate for learning and development purposes
(NMBA, 2007; Nursing & Midwifery Council, 2015; Quallich, 2005).
When delegating to another worker, it is important for the RN to
practice the appropriate level of supervision, which incorporates
education, guidance, direction, and monitoring and evaluating out-
comes (NMBA, 2007, p. 19; Nursing & Midwifery Council, 2015).

Efficient delegation and supervision in nursing practice is a com-
plex process that requires the nurse to use critical thinking, rational
decision- making, risk assessment processes and positive interper-
sonal skills (Bittner & Gravlin, 2009; NMBA, 2007; Weydt, 2010).

Supervision and delegation are an inherent part of the nurses’ role,
and therefore, it is important to examine the understanding and ac-
ceptance of these practices and factors influencing them in the nurs-
ing team. Evidence in the literature demonstrates the importance
of the relationship between successful delegation to teamwork and
quality patient care (Bittner & Gravlin, 2009; Potter et al., 2010).

1.1 | Literature review

Internationally, nursing care is commonly delivered by a team of
workers of differing levels of experience and qualifications (Kalisch &
Lee, 2013; Kalisch et al., 2013). Delegation and supervision are an in-
trinsic component of working as part of an effective multi- tier/multi-
skilled healthcare team to deliver high- quality patient care (Potter
et al., 2010). As the scope of practice of nurses and NA positions
evolve to meet the pressures on the healthcare systems globally, it
is important that each member of the nursing team understands and
operates their role and responsibilities in the delegation and supervi-
sion process. The importance of effective supervision and delegation
practices in the nursing team has been recognised internationally.

Delegation is described as a process of mutual understanding of
specific results expected and how those results are achieved (Potter
et al., 2010). Standing and Anthony (2008) found that nurses viewed
delegation as either the explicit act of instructing the NA to perform
a task, or implicit delegation, whereby the NA attends to duties as
part of the routine practice of their role. Magnusson et al. (2017,
p. 46) reported five styles of delegation; (a) the do- it- all nurse, who
completes most of the work themselves, (b) the justifier, who over-
explains the reasons for decisions and is sometimes defensive, (c)
the buddy, who wants to be everybody’s friend and avoids assuming
authority, (d) the role model, who hopes others will copy their best
practice but have no way of ensuring how, and (e) the inspector, who
is acutely aware of their accountability and constantly checks the
work of others. Each of these styles was shown to potentially have a
negative outcome and be poorly received by the NA thus impacting
teamwork. The authors argue that nurses need to exercise personal
authority and assertiveness for effective delegation practice and re-
quire support and a safe space to enhance these skills (Magnusson
et al., 2017).

Successful delegation between nurses and NAs depends on
multiple factors including communication, teamwork, initiative,
system support, nursing leadership, positive interpersonal rela-
tionships and attitudes, work environment, ward culture, work-
load and characteristics and the NA’s competence and knowledge
(Bittner & Gravlin, 2009; Gravlin & Bittner, 2010; Johnson et al.,
2015; Potter et al., 2010). It is important for nurses to learn skills
to delegate effectively, such as critical thinking, negotiation and
assertiveness to ensure patient safety and quality of patient
care (Bittner & Gravlin, 2009; Magnusson et al., 2017; Potter
et al., 2010; Schluter et al., 2011). Bittner and Gravlin (2009)
report seven factors relevant to critical thinking and delegation
between the nurse and NA which are knowledge, expectation,

| 3 of 10WALKER Et AL.

relationships, role uncertainty, communication barriers, system
support and omitted care. These findings are supported in the lit-
erature (Hasson et al., 2013; Magnusson et al., 2017; Potter et al.,
2010; Standing & Anthony, 2008).

The purpose of delegation is to gain work efficiency, which
Potter et al. (2010) argue can only be achieved when nursing team
members work together in partnership. Problematic delegation may
have negative impacts on patient care and teamwork (Allan et al.,
2016; Bittner & Gravlin, 2009; Johnson et al., 2015). Johnson et al.
(2015) argue that poor delegation can lead to nurses and NAs work-
ing in parallel rather than as an integrated team. They found that
ward culture, personal working styles, skills and competencies, and
effective communication were factors that informed collaborative
nursing between newly qualified nurses and NAs. Ineffective del-
egation practices and poor communication appear to be a source
of conflict between nurses and NAs, thus effecting teamwork and
quality of patient care (Johnson et al., 2015; Potter et al., 2010).
Researchers argue this conflict is accentuated by a lack of under-
standing and comprehension by NAs of the role and duties of the
RN, with NA’s perceiving very little difference between their roles
(Potter et al., 2010; Standing & Anthony, 2008).

Effective communication was shown to be essential to the del-
egation process and the follow- up of completed duties (Anthony &
Vidal, 2010; Gravlin & Bittner, 2010; Potter et al., 2010; Wagner,
2018). Communication issues, such as sharing information pertinent
to the patient and patient care plan, understanding delegated du-
ties, absence or lack of communication or reporting, and communi-
cation styles were also consistent findings (Bittner & Gravlin, 2009;
Gravlin & Bittner, 2010; Potter et al., 2010; Standing & Anthony,
2008; Wagner, 2018). There is a high expectation on NAs to report
back abnormal findings and demonstrate prioritisation skills, which
is beyond their knowledge and skill level (Bittner & Gravlin, 2009).
Researchers argue that poor communication and ineffective com-
munication styles have potentially negative outcomes for patient
care and nursing teamwork (Bittner & Gravlin, 2009; Wagner, 2018).

The nurse and NA interpersonal relationship was found to influ-
ence the effectiveness of the delegation process (Anthony & Vidal,
2010; Gravlin & Bittner, 2010). In situations where a positive rela-
tionship was perceived between the nurse and the NA, delegation
was enhanced (Gravlin & Bittner, 2010; Potter et al., 2010; Standing
& Anthony, 2008). Mutual trust is a consistent finding for successful
delegation (Anthony & Vidal, 2010; Bittner & Gravlin, 2009; Standing
& Anthony, 2008). The perception of the importance of the recipro-
cal nature of the nurse– NA relationship is also discussed (Standing &
Anthony, 2008). Other influences on the delegation and supervision
relationship considered in the literature are individual personality char-
acteristics, work ethic, favouritism, the fear and frustration of working
with poorly performing NAs, fear of reprimanding wayward NAs, the
reluctance of NAs to accept duties, nursing confidence to delegate
and the perception of nurses handing off the “dirty work” (Potter et al.,
2010; Saccomano & Pinto- Zipp, 2011; Standing & Anthony, 2008).

The nurses’ acceptance of their accountability for the work del-
egated to the NA was explored in the literature (Alcorn & Topping,

2009; Potter et al., 2010; Standing & Anthony, 2008). There was ev-
idence that some nurses believe they should not be accountable for
the actions of others (Alcorn & Topping, 2009; Hasson et al., 2013).
A “red flag” in this space was reported by Hasson et al. (2013), where
46% (n = 204) of student nurse participants indicated they did not
believe a nurse should have to supervise the NA, while 78% (n = 342)
did not believe their nursing training had prepared them to work
alongside NAs. Delegation and accountability are complicated by
the variation in the scope of practice expected of the NA and nurses
uncertainty about the role boundaries. Clarity and education on
accountability and delegation and supervision practices were advo-
cated (Bittner & Gravlin, 2009; Hasson et al., 2013; Wagner, 2018).

The movement towards diluting the nursing skill mix around the
globe means nurses are responsible for the delegation and supervi-
sion of lower trained workers within the nursing team. Evidence in
the literature demonstrates the importance of the relationship be-
tween successful delegation to teamwork and quality patient care
(Bittner & Gravlin, 2009; Potter et al., 2010). It is important to under-
stand how supervision and delegation are practised in the nursing
team to enhance patient care and teamwork.

2 | METHODS

In this study, an exploratory descriptive research design was un-
dertaken to examine the supervision of NAs practising in an acute
hospital setting, triangulating multiple sources of evidence. Nursing
leaders (policymakers, managers, supervisors and educators)
(n = 20), nurses (RN/EN) (n = 74) and NAs (n = 10) from 13 medical,
surgical and specialty wards of a tertiary hospital in Victoria Australia
participated in this research. To be included participants had to have
had direct involvement in the development or implementation of the
NA model, worked directly with the NA in the acute ward environ-
ment (>3 months) or worked in the role of a NA (>3 months) at the
hospital organisation. Recruitment and demographic information is
listed in Table 1. Ethical approval for the research was obtained from
the relevant University and Hospital organisation ethical review
boards, and this research was conducted according to the principles
and values of ethical conduct, as specified in the National Statement
on Ethical Conduct in Human Research (2007).

Data were collected using semi- structured individual interviews
(24), focus groups (11 focus groups with average of 6 participants)
and documentary information in the period between September
2013 and March 2014. Participants were accessed and recruited via
various means, including advertisement posters in the hospital, re-
searcher presentations on wards, word of mouth, networking and
through gatekeepers such as nurse managers and nurse educators.
Recruitment was guided by the concept of data adequacy, and the
accessibility and willingness of stakeholders to participate in the re-
search. Interviews and focus groups were guided by semi- structured
interview questions which were peer- reviewed for content valid-
ity and then refined, through progressive focusing. The interview
guides were developed to reflect the research aim and to collect

4 of 10 | WALKER Et AL.

information that would inform and provide a comprehensive de-
scription of the topic under study.

Documentary evidence was used to augment and provide con-
text to the information learned from the interview and focus group
process. Both publicly and privately accessible documents were
reviewed and included: organisational documents such as policies
and administrative documents, academic documents such as for-
mal papers and evaluations, government reports and inquiries, and
government and industrial body communication and information re-
leases. Interviews and focus groups were conducted by the primary
researcher. They were audio- recorded and transcribed verbatim by
the researcher and manually analysed. The thematic data analysis
for this research consisted of data condensation, data display, and
conclusion drawing and verification as outlined by Miles et al. (2014).
The analytical tactics were configurational (the what), normative
(the how) and field (the why) analysis as per Vincent and Wapshott
(2014).

Rigour was maintained through a comprehensive description of
the case and systematically following and presenting the research
design as per Yin (2014). This research aimed to be relatively value
neutral and free of bias, building objectivity within the research pro-
cess as outlined by Miles et al. (2014) and Holloway and Wheeler
(2010). Transcripts of individual interviews were sent back to

participants for verification. A sample of focus group transcripts
were reviewed by the research team to verify the interpretation of
the meaning expressed by participants. Triangulation of multiple
sources of data was utilised to verify conclusions drawn from the
data analysis. The researcher ensured that the documents collected
were from a variety of sources with a variety of purposes, and in-
tended audiences to maintain a balanced representation of the evi-
dence available. A wide net was cast for recruitment of participants,
with the aim of recruiting participants that reflected the full stake-
holder population. This examination of supervision and delegation
practices in the multi- tier nursing team was completed as a compo-
nent of a larger research project examining a Nursing Assistant (NA)
role practicing in the acute hospital setting.

3 | FINDINGS

3.1 | Clarity in the framework of care delivery in
the practices of supervision and delegation

The importance of building a clear framework of care delivery in
the practices of supervision and delegation in the context of the
multi- tiered nursing team was reported in this research. Nurse

TA B L E 1 Demographics of research participants

Embedded unit of
analysis

Nurse Leader
Total recruitment: 20

Nurse (RN/EN)
Total Recruitment: 74

Nursing Assistant
Total Recruitment: 10

Role Senior Managers/ Policy Makers— 9
NUM— 6
Nurse Educators— 5

RN— 68
EN— 6

NA— 10

Age

Age Range (years)

No. of
Participants

Age Range (years) No. of
Participants

35– 44
45– 54
55– 64

9
8
3

18– 24
25– 34
35– 44
45– 54
55– 64

10
34
13
13
4

18– 24
25– 34
45– 54
55– 64

3
1
5
1

Gender Male 5 Male 6 Male 2

Female 15 Female 68 Female 8

Years of
Experience in
Current Role

Years of
Experience

No. of
Participants

Years of
Experience

No. of
Participants

Years of
Experience

No. of
Participants

1– 2 years
3– 5 years
6– 10 years
>10 years

6
5
7
2

RN:
<1 year 1– 2 years 3– 5 years 6– 9 years 10– 15 years > 15 years
EN:
6– 9 years
10– 15 years
>15 years
unknown

RN:
6
10
16
16
15
5
EN:
1
1
3
1

1– 2 years
>2 years

3
7

Additional
Information

Acting Nurse Manager (ANUM)— 9 RN
participants

Clinical Nurse Specialist— 11 RN
participants

| 5 of 10WALKER Et AL.

leaders promoted the importance of developing clear guide-
lines and education to “ensure that the RN, EN, the NA all work
within their scope of practice and all three parties are aware of
their roles and responsibilities when it comes to supervision and
delegation and accountability” (NL8). Despite this, there were in-
consistencies in the interpretations of these guidelines and how
they were operationalised in practice, which had the potential to
impact teamwork and the quality of patient care. It was acknowl-
edged that although nurses and NA may know what tasks a NA
could perform if they “put it all into an accountability supervision
delegation framework, I think you might find a bit of confusion”
(NL8). This may have been complicated by pre- existing “greyness”
in the scope of the RN and the EN roles in the multi- tiered nurs-
ing team.

Variations in the interpretation of supervision and delegation
guidelines existed at all stakeholder levels (nurse leaders, RN and
EN, and NA) thus effecting horizontal (peer to peer) and vertical re-
lationships (different stakeholders) and associated teamwork. NAs
expected that they “were going to work side by side with a RN,
so she would be giving us our instructions and our directions and
she would work with us and we would be part of a team” (NA4).
However, they expressed disappointment “that hasn’t happened …
we’re very much left to ourselves” (NA4). Contrary to this, other NAs
embraced the autonomy in their role and did not perceive an ab-
sence of supervision and delegation by the RN “it may be unspoken
but I always feel that they [nurses] are supervising me” (NA1). Where
NA felt they were inappropriately supervised, they expressed frus-
tration and anxiety.

Multiple factors influenced the understanding and practices of
supervision and delegation within the multi- tier nursing team includ-
ing the: interpretation and understanding of policy, trust, collegiality,
individual work priorities, prior experience, and ward culture and ac-
cepted practices. Nurse leader views on the level of supervision re-
quired for a NA ranged from very conservative, one arguing “I don’t
think any [NA] should ever be left alone with a patient” (NL1), to a
broader perspective:

A RN might ask the [NA] to do a shower while they go
to tea, so they’re not there but the assumption is that
when you go to tea somebody else is kind of keeping
an eye on your patients.

(NL5)

Addressing these variations is essential as nurse leaders confirmed
the importance of appropriate supervision and delegation “because if
we don’t get that right, then it dilutes the effectiveness of the [NA]
role” (NL2). Nurses also held diverging views on the practice of su-
pervision and delegation of the NA one nurse stating “we don’t really
follow them around and put them under the microscope because we
consider them part of the team” (N10). Whereas another nurse ac-
knowledged “we could probably do it [supervision of the NA] better”
(N1). There were some nurses that perceived supervising the NA as
an additional burden one RN referred to the NA as “someone else you

have to supervise and make sure that they haven’t disappeared” (N9).
They described being “slowed down” by supervision requirements of
a NA trainee.

Due to the variability in the understanding and interpretation of
the NA role boundaries, NAs were required to communicate clearly
the duties they were allowed to assist with. Nurse leaders promoted
building an inclusive team environment where the NA was empow-
ered and “encouraged to speak up if they’re unsure or if they’re not
able to do it” (NL4). It was recognised that “as a [NA] you have to be
really strong to say “look I can’t do that” (NL2). A senior nurse leader
commented that “they [NAs] actually became very much the police
of their own scope of practice” (NL9). In light of this, there was a
concern that “some of them [NAs] may feel they don’t have the right
to say no to nurses because we are supervisors of them” (NL6), and
“some of them [NAs] will just do it because they have been asked”
(NL2). Further, concern was expressed that the NA may not identify:
“‘I’m not a nurse’ just let it kind of slide, it just depends who the [NA]
is” (NL3) which may have potential negative outcomes for patient
care.

3.2 | Confidence and understanding in
supervision and delegation practices.

Supervision and delegation practices within the multi- tiered nurs-
ing team involve a complex assessment and decision- making pro-
cess. The nursing team require an understanding of each team
member’s roles, responsibilities, skill level and competencies of
individuals. Patient condition and care needs must also be consid-
ered. It was recognised that “as the RNs we are legally responsible
for them [NA], so it’s quite critical that our new staff and grads
[New Graduate Nurses (NGN)] understand their responsibilities”
(N6).

Appropriate supervision and delegation practices were identi-
fied as being of such significance that it was a common understand-
ing by nurse leaders that casual pool/ agency staff and NGNs were
precluded from supervising and delegating to NAs, as these staff
potentially had a “poorer understanding” (NL2) of requirements in
a particular ward setting. In the case of the NGNs, nurse leaders
argued they should not be allocated an NA to assist them as “they’re
[NGNs] still struggling with their own time management and prac-
tice… better for them to be looked after by the rest of the team
rather than NAs” (NL4). However, this did not translate into practice,
as both casual pool/ agency staff and NGNs described practising su-
pervision and delegation of NAs.

New graduate nurses participants acknowledged that they were
regularly assisted by the NA position but felt underprepared for
the leadership responsibility suggesting that further preparation
for supervising and delegating to the NA would be beneficial “I’m a
grad and I don’t really know much about them [NA]… I find it hard, I
don’t know all supervision stuff and what actual tasks they can do”
(N11). A lack of confidence in their ability to delegate and supervise,
combined with a weaker understanding of the boundaries of the NA

6 of 10 | WALKER Et AL.

role, impacted some NGN’s willingness to delegate without direct
supervision “I usually use them as my extra pair of hands. So if I’m
mobilising, or if I’m doing a bed wash and I need that extra pair of
hands, so I am with them” (N12). The potential negative impact of
this lack of confidence and understanding was demonstrated when
a NA “went out of their scope of practice because she was trying to
help a NGN and the graduate didn’t have the confidence to actually
stop the person doing what they were doing… the problem, lack of
experience with the role and lack of understanding around what the
role could do lead to that issue” (NL10). This supports the need for
a clear framework for supervision and delegation and ensuring that
those participating have a strong understanding of each party’s roles
and responsibilities.

3.3 | Collegiality, respect and trust in the
delegation and supervision process

Nurses expressed greater comfort in delegating a range of duties
and providing low- level supervision where higher levels of collegi-
ality and trust existed between nurses and NAs. This was further
strengthened where there was the perception that the NA displayed
a strong work performance, high competency level and had recep-
tive attitude. One RN noted “if you’ve asked them [NA] to do some-
thing and they’ve done it well, then you know that you can ask them
to do it again” (N2). Contrary to this, where there were lower levels
of collegiality and more mistrust, nurses expressed less confidence
in the NA abilities and work performance as reflected by the follow-
ing “if they [NA] don’t seem confident then you’re not really going to
leave them on their own” (N3). In these situations, nurses reported
that they tended to avoid delegating tasks and provided higher levels
of supervision where possible. Nurses with less confidence in the
NA revealed that they preferred to use the NA “as a second pair of
hands” (N4), rather than delegate duties that required the nurse to
practice indirect supervision. It should be noted that there was a
concern that too much trust and comfort between the nurse and
NA may have a negative impact on supervision practices as “the
more experienced they [NAs] become you trust them a bit more”
(N5) leading to nurses becoming “quite blasé about supervision and
delegation” (N6).

In the multi- tiered nursing team, nurse leaders identified the
potential of nurses to inappropriately delegate tasks and take ad-
vantage of the NA, expecting them to do the ‘dirty work’ or to “del-
egate and forget… or a situation where the registered staff delegate
off everything and then leave themselves with perhaps not much
more than medication to work through (NL5). There was agreement
among the nurses that “some people [nurses] rely on them [NAs]
too much sometimes” (N13), “some people are NA hogs” (N14), and
these nurses were inconsiderate of the needs of other nursing team
members. There were further concerns that nurses will “leave those
things [dirty work] because they expect the [NA] to do them” (NL11)
thus potentially resulting in care being missed. The unstructured

nature of the NA workload created the potential for NA to be del-
egated heavy workloads and create tension within the team should
the NA refuse to accept a delegated duty.

3.4 | Operationalising direct and indirect
supervision.

Nurse leaders challenged the idea that the RNs were new to super-
vision and delegation due to their responsibilities when working
with ENs and student nurses “it should be similar in following the
same principles as how they work with the ENs, how they work
with novice and beginner nurses and nursing students as well”
(NL9). One nurse leader identified that the introduction of the NA
“made me understand that it did not really dawn on them [RNs]
how much they were responsible for the supervision and delega-
tion of ENs” (NL12).

Nurses were able to define direct and indirect supervision,
but there were inconsistencies in their interpretation of when to
apply the different levels of supervision. This was evident in a focus
group disagreement where nurses argued whether a nurse was re-
quired to remain on a ward when indirectly supervising a NA, or if
this responsibility passed to the nurse covering the nurse while off
the ward on break “you’ve always handed over to the nurse next
door anyway so they’re indirectly responsible” (N7). In addition to
this, many nurses expressed the belief that the nurse in charge was
responsible for supervising and delegating to the NA, not identify-
ing their role in explicit delegation and supervision responsibilities
that ensue. Participants who acted as nurse in charge rebutted this
assertion, arguing they were too busy to know what the NA was
doing “as an in charge I never see her because she’s always out…
it’s more up to the girls on the floor that are working with her and
alongside her” (N8).

Some nurse leaders expressed concerns about the nurses under-
standing and practice of indirect and direct supervision “they [RNs]
really don’t understand concepts of supervision direct, indirect and
accountability… I really don’t think that they even think about it
much the NA just comes in and does the work” (NL13). The nurse
leader then provided an example of a situation where the NA had
been left in a vulnerable position as the RN had “propped open the
door of the drug room so the health assistant can go in and restock…
they aren’t thinking the NA should not be in there without a RN
present” (NL13). Other nurse leaders agreed that supervision and
delegation are an area that nursing could improve.

When considering how to improve supervision of NA in practice
one nurse leader identified “the risk is sometimes that you can over
supervise people particularly when a role is new because you’re
worried that people will work outside of scope” (NL14). Further to
this “because supervision is generally indirect and not direct and
you would argue that if you had to give direct supervision all the
time there’s no point having the role” (NL14). This nurse leader also
indicated “I don’t think supervision could be improved but I think

| 7 of 10WALKER Et AL.

possibly giving people, giving people a bit more room, bit more flex-
ibility in the role”(NL14); again highlighting the divergent views on
supervision and delegation practice of the NA in the acute hospital
setting.

3.5 | Understanding accountability and
responsibility

The nurses’ understanding of their accountability and responsibility
was intrinsically linked to their individual understanding and expec-
tations of the practice of delegation. There were variations in the
expectation and understanding of the nurses’ accountability when
working with the NA. In theory, the nurses understood that they were
accountable and responsible for the duties they delegated to the NA;
however, how this was interpreted and practised in the ward environ-
ment varied between individual nurses. When this issue was explored
in detail in the focus groups, nurses were often divided as to what
they should be held accountable for “if they’ve [the NAs have] been
signed off on something in their training then they should be account-
able for what they do” (N10); contrary to this, others argued “that’s
not the way it is… we are accountable… you’re responsible (N11).

When the NA position was first introduced, nurses expressed
concern at being accountable for another healthcare team member;
however, they indicated that their experience working with the NA
had dulled some of those concerns. It was argued that the NA had
become embedded into the culture of the nursing team, and there-
fore, the nurse was no longer mindful of their accountability and re-
sponsibility, it had just become part of the daily routine as “I don’t
think the RNs would consciously be thinking of it [their account-
ability and responsibility] it’s just kind of now culturally embedded
into how we practice on a day to day (NL6). There was concern that
trust between the nurse and NA may result in nurses “abdicated that
[accountability and responsibility of the delegated task] because we
have so much faith in our NA” (NL7). One nurse leader noted “they’re
[nurses are] very good at delegating probably less good at supervis-
ing” (NL15). There were nurse leaders that expressed concern that
nurses continue to ask questions about “what accountability was,
their responsibility was and they’re still not clear.” (NL13). Further
to this, there are some nurses that continue to have “an incredible
amount of anxiety about their legal role related to supervision and
delegation” (NL12).

3.6 | Improving supervision and delegation through
education and information

Nurse leaders argued that education, clarity in the supervision and
delegation space, and support within the ward environment, would
improve the practice and understanding of supervision and del-
egation and accountability. At the ward level, the nurse managers
promoted a clear support structure, further education, and clear

and consistent guidelines to ensure supervision and delegation of
the NA was of a satisfactory standard. It was noted by one nurse
leader that:

Being able to supervise and delegate incorporates
skills such as being able to give feedback… leadership
skills being able to critically appraise activities what
needs to be done how to delegate those activities
they’re all skills and from my experience, I don’t see
many RNs having those skills.

(NL1)

Thus, impressing the importance of ongoing education in this space
“we are going to have to do a revisit on the NA… I think that there is
a real need for it” (NL13). This was supported by the NAs and many
of the nursing participants. Educators recommended that ongoing
education for the nursing team should involve practical examples and
opportunities for open discussion, so nurses may gain a greater under-
standing of the practical application of the principles of supervision,
delegation and accountability. Those who rejected the need for further
education believed that supervision and delegation were practised al-
ready to satisfactory levels. Mutual understanding and transparent
practices at the team level is important for supervision and delegation
in the multi- tiered nursing team as nurses need to be “comfortable and
confident with their scope of practice and their role in supervision and
delegation and the framework they deliver care in” (NL8).

4 | DISCUSSION

This research found that supervision and delegation practices in the
multi- tier nursing team are complex and influenced by multiple fac-
tors. It supports the importance of mutual understanding and trans-
parency in the nursing team to facilitate appropriate supervision
and delegation. It suggests that more transparent practices within
the nursing team could build better shared expectations and per-
formance of supervision and delegation with the aim of improving
patient care, teamwork and role satisfaction. Palanski et al. (2011)
define team transparency as “the sharing of information and expla-
nations within a team to enable its members to carry out their re-
sponsibilities within the team” (p. 203) and Horne (2012) argues that
transparency requires openness, disclosure and the free- flowing
sharing of knowledge. This research finds effective communica-
tion is an essential part of this process, requiring the nursing team
to feel empowered to openly and honestly communicate, sharing
knowledge and feedback in a collegial way to maintain the quality
of patient care.

In line with previous research on nursing supervision and del-
egation, this study indicated mutual understanding, knowledge,
skills, competence, collegiality, attitude, ward culture, communica-
tion, interpersonal skills, workload, teamwork, support and initiative
influenced delegation and supervision practices (Bittner & Gravlin,

8 of 10 | WALKER Et AL.

2009; Gravlin & Bittner, 2010; Potter et al., 2010; Weydt, 2010).
The multiplicity of factors affecting nursing supervision and dele-
gation practices within the multi- tiered nursing team culminates
in a complex assessment and decision- making process requiring
team members to be well informed and have access to appropriate
information. Individual characteristics, skills and attitudes of team
members and leaders add further complexity and inhibits a one size
fits all approach. The multilayered complexity substantiates the im-
portance of transparent practices so that the needs of the situation,
environment and individual actors may be taken into consideration
and informed decisions made.

A lack of understanding about delegation, and responsibilities
and accountabilities in the delegation relationship, is associated with
nurses fearing to delegate tasks and an increased risk of burnout
(Quallich, 2005). This research supports the idea that nurses are
more reluctant to delegate duties or provide indirect supervision in
situations where they were not confident, had mistrust or lacked an
understanding of the requirements of delegation and supervision.
Conflict was present where there was a lack of mutual understanding
as team members held mismatched expectations and understand-
ing of roles and responsibilities, requirements for supervision, and
workload and initiative which were further complicated by individual
personalities. This supports Potter et al. (2010) finding that there are
multiple sources of conflict within the nurse/NA relationship. A lack
of understanding of practices and conflict within the nurse– NA re-
lationship had the potential to inhibit fulfilment of the intentions of
the role, which was to allow nurses to work to the upper end of their
scope, improve the patient experience and improve staff retention.
This is important as the APPG Triple Impact report (2016) identi-
fies that it is important for nurses to work to their full potential and
strengthening nursing will positively impact health, gender equality
and economic growth.

The inclusion of the NA to the nursing team requires the RN to
embrace their role as a leader and to be more cognisant of their re-
sponsibility and accountability as a professional nurse. The Nursing
Now campaign draws attention to the need to nurture nurses’ lead-
ership skills and allow nurses to work to their full scope of practice to
strengthen the nursing workforce (World Health Organisation. et al.,
2020). This is even more important as the demands on nurses surge
from the pressures of the COVID 19 pandemic. In this research,
nurses accepted their accountability when delegating to others;
however, how this was conceptualised differed between individuals,
which was consistent with the literature (Alcorn & Topping, 2009;
Hasson et al., 2013; Potter et al., 2010; Standing & Anthony, 2008).
Nurses need a clear understanding of their accountability and re-
sponsibility when delegating to others to ensure that appropriate
supervision is provided reducing the potential for errors and neg-
ative patient outcomes (Standing & Anthony, 2008). This should be
supported by clear and consistent policies and guidelines.

As a leader, the nurse should role model professional behaviour
acting respectfully and delegating a fair and balanced workload
to the NA position. This should be supported by organisational
structures and policy. The Nursing Now campaign recognises the

importance of healthcare organisations providing an “enabling en-
vironment” for nurses, to promote retention and motivation in
the nursing workforce (World Health Organisation. et al., 2020).
Collegiality, trust and a willingness to collaborate within the nursing
team are important to enhancing teamwork, role satisfaction, the
quality of patient care and professionalism in the healthcare envi-
ronment (Gravlin & Bittner, 2010; Padgett, 2013; Potter et al., 2010;
Standing & Anthony, 2008). There was concern in this research of
a potential tipping point where overconfidence, comfort and trust
in collegial relationships may result in inappropriate delegation and
supervision practices as camaraderies may overshadow responsibil-
ities and accountabilities. It is important that there is transparency
in delegation process and that team members are empowered to
communicate openly and honestly ensuring the NA practices within
their role boundaries and competency level with appropriate level
of supervision.

Education on the roles and responsibilities of team members and
the practices of supervision and delegation within the multi- tiered
nursing team is important in building transparent practices and in-
formed decision- making processes. Practical examples and scenar-
ios were recommended in this research to assist nurses gain a deeper
grasp of this. Focus should also be placed on the importance of inter-
personal relationships within the nursing team and effective leader-
ship skills for nursing staff (Anthony & Vidal, 2010; Gravlin & Bittner,
2010; Magnusson et al., 2017). Similar to previous research, there
was concern that newly qualified nurses and nursing students were
ill prepared for the demands of delegation and supervision within
the clinical setting and that there was a presumption that nurses
learnt these skills “on the job”(Allan et al., 2016; Hasson et al., 2013).
As the Nursing Now campaign encourages nurses to embrace their
role as a leader, optimising their scope of practice and maximising
their impact, it is important that nurses are provided the foundation
on which to build these skills and abilities through introducing these
concepts at an undergraduate level and empowering continual life-
long learning and practice (World Health Organisation. et al., 2020).

5 | CONCLUSION

Supervision and delegation in the multi- tier nursing team involve
a complex assessment and decision- making processes that are in-
fluenced by multiple factors. Members of the nursing team need to
have a strong understanding of their roles and responsibilities and
the practices of supervision and delegation. This research promotes
the need for developing transparency in the team environment
through sharing information and explanations in decision- making
processes, building a culture of openness and trust, growing aware-
ness in the roles, capabilities and responsibilities of individuals, and
making practices clear and evident. Transparency in the nursing team
will help inform and enhance supervision and delegation practices,
thus empowering the team to practice confidently within their scope
of practice in providing quality patient care. This is important as poor
delegation and supervision may result in negative patient outcomes

| 9 of 10WALKER Et AL.

(Potter et al., 2010; Ray & Overman, 2014; Standing & Anthony,
2008). Education is important in supporting nurses in the practice
of supervision and delegation. As the prevalence of the multi- tiered
nursing team increases, a greater focus should be placed on these
and other leadership skills within the undergraduate education of
the professional nurse.

ACKNOWLEDG EMENTS
The researchers acknowledge the support of an Australian
Government Research Training Program Scholarship for this re-
search. We also thank the hospital setting for their support of this
research.

ORCID
Felicity Ann Walker https://orcid.org/0000-0001-7576-1937

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How to cite this article: Walker FA, Ball M, Cleary S, Pisani H.
Transparent teamwork: The practice of supervision and
delegation within the multi- tiered nursing team. Nurs Inq.
2021;00:e12413. https://doi.org/10.1111/nin.12413

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https://doi.org/10.1111/nin.12413

Accepted: 1 October 2017

DOI: 10.1111/jonm.1258

O R I G I N A L A R T I C L E

Nursing teamwork in a health system: A multisite study

Jennifer A. Kaiser PhD, MSN, RN, CNE, Senior Nurse Researcher1 | Judith B. Westers
MSN, BSN, RN, Director of Pediatric Services2

1Spectrum Health, Grand Rapids, MI, USA
2Helen DeVos Children’s Hospital, Grand
Rapids, MI, USA

Correspondence
Jennifer Kaiser, Spectrum Health, Grand
Rapids, MI, USA.
Email: jennifer.kaiser@spectrumhealth.org

Funding information
This research did not receive any specific
grant from funding agencies in the public,
commercial, or not- for- profit sectors.

Aim: The aim of this study was to examine how the facets of teamwork exist among
nurse- only teams in acute and continuing care settings.
Background: The health care ‘team’ conventionally describes the interdisciplinary team
in both literature and practice. Nursing- specific teams are rarely considered in the
literature. An examination of this specific professional cohort is important to under-
stand how teamwork exists among those who provide the majority of patient care.
Method: This was a descriptive, comparative, cross- sectional study using the Nursing
Teamwork Survey to measure teamwork of nursing- based teams among 1414 partici-
pants in multiple acute care environments across a large Midwestern health system.
Results: The characteristics of nursing teams were analysed. The results from the sub-
scales within the teamwork model showed that nursing teams had a good understand-
ing of the various roles and responsibilities. However, nurse team members held a
more individualistic rather than collective team- oriented mindset.
Conclusions and Implications for Nursing Management: Increased teamwork has a
positive effect on job satisfaction, staffing efficiencies, retention and care delivery.
Nurse leaders can use the information provided in this study to target the aspects of
highly functioning teams by improving team orientation, trust and backup
behaviours.

K E Y W O R D S

nursing, team, teamwork

1 | AIM

The aim of this study was to examine how the facets of teamwork
exist among nurse- only teams in acute and continuing care settings.
The facets of nursing teams were explored using a similar conceptual
framework to those widely examined in the literature. The principal
objective was to determine how acute care nursing teams align with
the standards of highly effective teams in other professional domains.
Additional questions to be answered included:

(1) What is the average level of nursing teamwork based on the
characteristics used to describe highly effective teams?

(2) Are there differences in average total teamwork among various
care settings (service lines)?

(3) Does one or more of the aspects of effective teamwork have a
stronger prevalence in acute and continuing care settings?

(4) Are there differences in the average total teamwork based on edu-
cation, gender, experience or work characteristics?

(5) Does teamwork correlate to job satisfaction, satisfaction with staff-
ing and intent to leave the position?

2 | BACKGROUND

In the landmark reports To Err is Human, Crossing the Quality Chasm
and The Future of Nursing, the Institute of Medicine clearly identi-
fied the importance of team processes to high- quality health care.

www.wileyonlinelibrary.com/journal/jonm

http://orcid.org/0000-0002-7686-021

mailto:jennifer.kaiser@spectrumhealth.org

2 | KAISER And WESTERS

Like safety culture and systems thinking, the benefits of teamwork
have been demonstrated in multiple industries including aviation,
nuclear medicine and the military (Baker, Day, & Salas, 2006; Salas,
Cook, & Rosen, 2008). These industries are considered ‘high reli-
ability organisations’, defined as organisations that operate with
low levels of safety events despite a complex hazardous environ-
ment (Agency for Healthcare Research and Quality, 2006). A con-
ceptual framework for highly effective teams has been established
in high- reliability organisations (HROs) and adopted into the health
care domain (Baker et al., 2006; Brady, Battles, & Ricciardi, 2015;
Gaston, Short, Ralyea, & Casterline, 2016; Jain, Thompson, Chaudry,
McKenzie, & Schwartz, 2008).

The common framework and interventions for teamwork thereby
originate from non- health care organisations. The Agency for
Healthcare Research and Quality (AHRQ) studied the processes of
teamwork in high reliability organisations and created TeamSTEPPS
(Team Strategies and Tools to Enhance Performance and Patient
Safety), a curriculum designed to improve teamwork skills and com-
munication among health care professionals (Agency for Healthcare
Research and Quality, 2006). TeamSTEPPS has been implemented in
areas most comparable to its prototype, namely emergency depart-
ments, surgical services, intensive care units and in situations such as
cardiac arrest (Jones, Podila, & Powers, 2013; McCulloch et al., 2017).
‘Teams’ among the predominant health care literature are primarily in-
terdisciplinary and largely situational or episodic as in surgery or emer-
gency situations (Gaston et al., 2016; Jones et al., 2013; McCulloch
et al., 2017).

To date there is little known research that provides a comprehen-
sive analysis of teamwork specific to the health care industry with its
own variants in practice, nor does the research on teamwork within
health care extend much beyond its original settings of surgical, criti-
cal and emergency care (Alexanian, Kitto, Rak, & Reeves, 2015; Baker
et al., 2006; Kalisch, Lee, & Salas, 2010). The vast majority of studies of
teamwork in health care are interprofessional (Alexanian et al., 2015;
Baker et al., 2006; Korner, Wirtz, Bengel, & Goritz, 2015). ‘Although a
large proportion of health care is delivered by nursing work teams in
acute care hospitals, there has been very little research about team-
work in this setting’ (Kalisch et al., 2010, p.42).

There are some key differences in the structure of nursing teams
versus the multidisciplinary health care team. Kalisch defines nursing
teams as the staff members – registered nurses, licensed practical
nurses, nursing support staff – who work together on a given patient
care unit. This nursing team provides the care and related administra-
tive tasks for a group of patients (Kalisch et al., 2010). A primary differ-
ence is that most professionals other than nurses spend time both on
and off the unit in their normal workflow. A specific time set aside for
collaboration, such as interdisciplinary rounds, is one of the few times
in which all the team members are physically located in the same space
and interacting face- to- face. Nursing teams continually work together
for extended periods of time and workflow among team members
directly overlaps.

Additionally, the ‘leader’ position of the interdisciplinary teams
described in the literature has been held primarily by medical providers

(Alexanian et al., 2015; Baker et al., 2006; Korner et al., 2015). This
history fails to consider nursing leadership in the team structure.
Numerous researchers have identified that leader–member relation-
ships directly affect the quality of team cohesion and effectiveness
(Brunetto, Shriberg, Farr- Wharton, Shacklock, & Newman, 2013). An
examination of teamwork with a nurse as the team leader may show
significant differences from previous studies and present a critical fac-
tor in teamwork.

The Nursing Teamwork Survey (NTS) was developed by Dr B.
Kalisch in response to a lack of a teamwork measurement tool specific
to health care with sound psychometric properties that could be used
in a variety of patient care settings (Kalisch et al., 2010). The NTS has a
reliability coefficient ranging from 0.77 to 0.87, and an internal consis-
tency alpha coefficient of 0.94. Additional factor analysis showed item
loading consistent with Salas’ Big Five framework (Kalisch et al., 2010).
A unique aspect of the Nursing Teamwork Survey is that it is designed
to focus specifically on nursing teams as opposed to interdisciplinary
healthcare teams.

The conceptual model for this tool is Eduardo Salas’ ‘Big Five’
framework of teamwork. Salas’ framework was selected as the basis
for the Nursing Teamwork Survey ‘because it is based on team-
work behaviours and offers a practical explanation of the dynamics
of teamwork’ (Kalisch et al., 2010; p. 43). The model upon which
the NTS is based has similar subscales and origins of the widely
used TeamSTEPPS® model developed by the Agency for Healthcare
Research and Quality (AHRQ), with five subscales congruent to those
in the NTS (Agency for Healthcare Research and Quality, 2006).

The ‘Big Five’ framework describes the knowledge, skills and atti-
tudes required for effective teamwork. Simply put, the model describes
the components of highly effective teams. True teamwork is defined as
more than parallel work and collaboration. As Salas describes, highly
effective teams consistently exhibit the following knowledge, skills
and attitudes:

• have a clear and common purpose
• compensate for each other
• regularly provide feedback to each other and the team
• self-correct
• anticipate each other’s actions and needs
• reallocate functions
• adjust their strategy under stress
• coordinate without the need to communicate
• value the team goals over individual goals, and
• strongly believe in the team’s collective ability to succeed (Baker

et al., 2006).

Extensive research suggests that teamwork is defined by this stan-
dard set of inter- related knowledge, skills and attitudes that facilitate
coordinated, adaptive performance (Baker et al., 2006). There are few
studies that have determined whether these standard knowledge, skills
and attitudes exist in nursing- specific teams.

Effective teamwork is a valuable aspect of patient care delivery.
Research has confirmed that the ability of health care to become a

| 3KAISER And WESTERS

high- reliability organisation (HRO) is dependent on its members to
effectively and efficiently coordinate their activities. Teamwork has
been found to increase the productivity of nursing work, enhance
job satisfaction and promote optimum quality of care. Teamwork
has also been linked to decreasing nurse stress, protecting patient
safety and promoting greater patient satisfaction (Kalisch & Lee,
2009). It is logical that an understanding of the structure and func-
tion of nursing teams is crucial in leveraging teams to realize these
outcomes.

3 | METHOD

This was a descriptive, cross- sectional study using the Nursing
Teamwork Survey to measure the teamwork of nursing teams in
multiple acute care environments across a large Midwestern health
system. Institutional IRB review #2014- 054 was obtained prior to
implementation.

The Nursing Teamwork Survey (NTS) was used to measure team-
work within the nursing work environment. The tool has demon-
strated validity, reliability and acceptability in previous studies (Kalisch
et al., 2010). This survey tool is unique in that the team members are
specific to nursing, and includes staff nurses (registered nurses and
licensed practical nurses), nursing assistants, nurse managers, charge
nurses and unit secretaries.

The June 2015 survey involved the participation of 74 units/
areas within 11 hospitals in the health system. Hospitals included
two large 1100 bed metropolitan health centres, a 190- bed multi-
specialty children’s hospital, and eight rural or suburban smaller re-
gional hospitals. Nursing units included were medical/surgical units
ranging from 22 to 48 beds; an acute rehabilitation unit of 20 beds;
rehabilitation continuing care services; a long- term acute care unit
of 25 beds; critical care units including neurosurgical critical care,
cardiac critical care, surgical critical care, and a 108 bed neonatal
intensive care unit; 24 bed paediatric units, and 24 bed obstetric
units in the urban and regional hospitals. Surgical services, emer-
gency services and more episodic teams such as interventional
areas were excluded from the sample. The study included any par-
ticipant who held the role of registered nurse, licensed practical
nurse, nursing assistant or technician, unit secretary, clinical nurse
specialist, nursing supervisor, nurse manager or nurse educator
within the designated nursing areas of practice. The purpose of this
broad sample was to capture a variety of nursing teams and prac-
tice settings.

A convenience sample of 1,414 nursing staff employees partici-
pated, constituting a 33% return rate. Probability sampling techniques
were not utilized and the response rate was low. However, a sample
size of 1,414 provides a ±2.6% sampling error. The ratio of sample
size to the number of survey items was 26:1, exceeding the minimum
recommended ratios (Osborne & Costello, 2004).

Staff nurses comprised 55% of the sample, with 53% registered
nurses. Twenty- three percent were nursing assistants, 4% were unit
clerks, and the remainder were nurse leaders (charge nurse, nurse

manager, supervisor, director, educator or clinical nurse specialist). The
majority (86.85%) of participants was female and the highest educa-
tion level of most of the participants was a bachelor degree (54.67%).
A small number of participants were new to their role (6%) or new
to the unit (11%) defined as less than 6 months. Interestingly, 25%
of the sample respondents were not licensed nurses, although com-
parison by role indicated that most of these individuals were nursing
assistants. Seventy- nine percent of participants worked full- time.
Fifty- three percent of participants reported working the day shift
(0700–1900) and 34% worked night shift (1900–0700). Forty- eight
percent did not work any overtime in the last 3 months, 87% missed
one shift or fewer in the last 3 months, and 74% had no intention of
leaving their position.

The survey asks the demographic items of educational level,
gender, age and job title. Work- related items include work shift and
years of experience. Satisfaction items relate to current position and
role, staffing adequacy and level of teamwork on the unit. Thirty-
three items measuring descriptors of teamwork are divided into five
subscales based on Salas’ ‘Big Five’ framework of teamwork. The
subscales are defined as:

• Shared mental model: All team members understand their role and
responsibilities and thus respectively work together to achieve a
quality work outcome.

• Team leadership: Charge nurses or managers adequately monitor,
distribute and balance the workload of the nurses.

• Backup: Team members willingly aid and help one another when
they recognize someone is busy or overloaded with work.

• Trust: Team members trust each other enough to communicate
ideas and information and value, seek and give each other construc-
tive feedback.

• Team orientation: The team works together to improve each other’s
weaknesses efficiently and effectively (Kalisch et al., 2010).

The survey was deployed to approximately 4200 nursing staff
within 11 hospitals and facilities in the health system via a secure
email link. Surveys needed to be completed in entirety for inclusion in
the study. Voluntary completion indicated consent.

4 | RESULTS

4.1 | Average level of nursing teamwork

The total teamwork system average was M = 3.614 (SD = 0.441)
on a 0–5 Likert scale. There is no benchmark score for this num-
ber. Compared with previous studies using the Nursing Teamwork
Survey, the health system used in this study appeared to be aligned
with other hospitals (Kalisch, Labelle, & Boqin, 2013; Kalisch & Lee,
2012; Pearson, Needleman, Beckman, & Han, 2015). Total teamwork
differed by hospital, F (11, 1,412) = 7.50, p < .0001; service line, F (8, 1,412) = 10.4, p < .0001; and unit F (45, 1,412) = 2.31, p < .0001. Figure 1 shows the total teamwork averages for the aggregate system (n = 1,414).

4 | KAISER And WESTERS

4.2 | Teamwork across care settings (service lines)

ANOVA found significant differences in total teamwork between care
settings (service lines) F (8, 1,412) = 10.40, p < .0001. Table 1 shows the mean calculations for each of the subscales of teamwork across service lines. Rehabilitation had the highest levels of total teamwork (M = 3.840) and continuing care (long term care) had significantly lower levels of total teamwork (M = 3.288).

4.3 | Aspects of effective teams: subscales

The aggregate averages for the five subscales are shown in
Figure 1. All care settings showed similar trends in subscales.
The mean (M) for the total system was highest for the shared

mental model subscale (M = 4.207, standard deviation [SD] of
0.582). Team leadership was also relatively higher within nurs-
ing teams (M = 3.991, SD = 0.801) than the remaining subscales,
the latter showing a higher sample variance (0.339 to 0.641 re-
spectively). The subscales of back up, trust and team orientation
generally showed a significant drop from shared mental model and
leadership across the system. The trust and backup scales showed
similar frequency of behaviours (trust M = 3.790/SD = 0.725;
backup M = 3.754/SD = 0.783). Finally, there was a marked drop
in team orientation behaviours, with a mean of 2.324 (SD = 0.732).
Regardless of the unit type or service line, the trend in subscales
was constant, which is a significant finding to support the notion
that nursing teams are similar regardless of the setting. Table 1
provides the averages for each subscale within each care setting.

F IGURE 1 Total teamwork averages:
system aggregate

4.21
3.99

3.75 3.79

2.32

3.61

Shared Mental
Model

Team
Leadership

Backup Trust Team
Orienta�on

Total Teamwork

Total Teamwork Averages
Shared Mental Model Team Leadership Backup

Trust Team Orienta�on Total Teamwork

TABLE 1 Teamwork across service lines

Service line

Shared mental
model Leadership Backup Trust

Team
orientation Total Teamwork

M SD M SD M SD M SD M SD M SD

System total
(n = 1,414)

4.207 0.582 3.990 0.801 3.754 0.783 3.790 0.725 2.324 0.732 3.614 0.441

Rehabilitation (n = 44) 4.487 0.480 4.375 0.347 4.318 0.513 4.231 0.567 1.790 0.539 3.840 0.265

Adult MedSurg
(n = 438)

4.335 0.517 4.024 0.591 3.911 0.714 4.001 0.630 2.114 0.651 3.677 0.373

Adult progressive care
(n = 204)

4.241 0.563 4.063 0.572 3.799 0.746 3.831 0.721 2.282 0.739 3.643 0.390

Adult critical care
(n = 214)

4.210 0.509 3.973 0.647 3.701 0.739 3.718 0.664 2.323 0.677 3.585 0.369

Women and infants
(n = 107)

4.233 0.501 3.843 0.759 3.776 0.730 3.746 0.696 2.504 0.699 3.622 0.397

Paediatric critical care
(n = 145)

4.107 0.552 3.886 0.617 3.652 0.731 3.667 0.645 2.487 0.737 3.559 0.343

Paediatric MedSurg
(n = 64)

4.241 0.512 4.043 0.561 3.911 0.598 3.821 0.606 2.306 0.597 3.644 0.329

Continuing care
(n = 105)

3.741 0.803 3.369 0.901 3.193 0.969 3.262 0.915 2.873 0.808 3.288 0.569

M, mean; SD, standard deviation.

| 5KAISER And WESTERS

Figure 2 displays the trends in subscales across care settings. This
graph shows a consistent and significant drop in team orientation
among all nursing teams.

4.4 | Differences in teams based on demographics

ANOVA was used to compare average perceptions of total teamwork
characteristics based on education, gender, age, experience and work
descriptors. For each of these aggregate characteristics the Bonferroni
method was used to adjust for multiple testing.

There was no significant difference in the average total teamwork
among males (LSM = 3.50) and females (LSM = 3.53) p > 1.0, nor
were there differences by level of education (p > .41–1.0). Nursing
teams on night/third shift (LSM = 3.58) reported significantly higher
levels of teamwork (p < .001) than those working on day/first shift (LSM = 3.46) or evenings/second shift (LSM = 3.47). The total team- work score for those with up to 2 years of experience (LSM = 3.58) was significantly higher than those with greater than 5 years of experience (LSM = 3.39), p > .05. Work characteristics such as the
amount of work missed and the amount of overtime worked had no
significant differences in overall teamwork.

4.5 | Teamwork and satisfaction

The average total teamwork score for those who had no plans to
leave their position within the next year (LSM = 3.52) was significantly
greater (p < .001) than the average total teamwork score of those who planned to leave their position within 6 months (LSM = 3.45, p > .40)
or within the next year (LSM = 3.39, p > .014). The data showed a
clear correlation (p < .001) between satisfaction with position and teamwork. There was sufficient evidence to show that the average total teamwork score was highest for those with higher perceptions of adequate staffing. All levels of perceived staffing adequacy showed significant difference with a clear decline in teamwork as perceptions of adequate staffing declines. These results have implications for job retention and satisfaction.

5 | CONCLUSIONS

Generally nursing teams had similar components to those of highly
effective teams in other industries as defined by the standards de-
scribed by Salas (Baker et al., 2006). However, there was variation in
the degree to which the nursing team expressed each of these com-
ponents. In highly effective teams these scales tend to be more evenly
distributed (Baker et al., 2006; Jain et al., 2008; Salas et al., 2008).
This presents an opportunity for improvement to make nursing teams
more congruent with prototype teams used as a model of practice.

The shared mental model subscale scored highest across the sys-
tem. The shared mental model is the structure of relationships and role
responsibilities within a team. High scores in this subscale means that
team members are clear on the responsibilities and tasks expected of
themselves and others. They feel they work well together and respect
and value each other as team members. One item of particular note
scored markedly low on this subscale: ‘team members are aware of
the strengths and weaknesses of other team members they work with
most often’. This becomes important as discussed in subsequent sub-
scales. It is significant to note that nursing teams tend to know whose
task and whose patient is whose but have less of an awareness of each
other as team members.

The team leadership subscale also scored consistently high, which
implores discussion. The predominant literature on health care teams
assigns the role of team leader to the physician or other medical pro-
vider. This is reflected in practice. However, satisfaction with and
efficacy of the physician/provider in providing the leadership skills
necessary to facilitate true teamwork is lacking. More typical of this
type of team is the role of the physician/provider to make decisions
based on information provided by other group members, but not nec-
essarily input provided by the same (Alexanian et al., 2015).

In contrast the NTS model assigns a charge nurse or nurse man-
ager the role of team leader. While nurse team leaders were perceived
as much more effective than the medical leaders of interprofessional
teams there remains a discrepancy between nursing teams and non-
health care highly effective teams. The leadership behaviours described

F IGURE 2 Trends for teamwork
subscales across care settings

1.5

2.5

3.5

4.5

Shared Mental
Model

Team
Leadership

Backup Trust Team
Orientation

Total
Teamwork

Rehabilitation Adult MedSurg Adult Progressive

Adult Critical Care Women and Infants Pediatric Critical Care

Pediatric MedSurg Continuing Care

6 | KAISER And WESTERS

in the NTS are very directive toward workload and team function. High
scores in this subscale mean that the team leader (charge nurse, su-
pervisor or manager) monitors progress, directs changes in the plan
and structure of responsibilities, and determines who should do what.
Conversely, a key feature of high- functioning teams is that they are
self- regulating, self- adaptable and markedly less dependent on a di-
rective leader. Salas describes the importance of a dedicated leader,
but in the most effective teams this aspect does not overshadow the
other components. The nursing teams in this study had a prominently
higher score in leadership compared with the other subscales indicat-
ing a dependence on leadership versus autonomous practice.

Subscales that scored lower across the nursing teams were backup
and trust. The backup scale describes team members who willingly aid
and help one another with their tasks and responsibilities. In partic-
ular, members monitor for and recognize when someone is busy or
overloaded and assist them in their work. When the workload is heavy
both team members and leadership pitch in to get things done. These
behaviours were not as evident in nursing teams. While the teams
value each other there is a predominant mindset of clear role delin-
eation and work assignments among nursing team members. Patients
are assigned to nurses and nursing assistants, and licensure often de-
termines task responsibility. Even within the same level and role, units
operate based on the care needed for assigned patients. Nurses feel
an obligation and often pressure to get everything done for their own
patient. Work left undone for the next shift is chastised and there is a
constant pressure to ‘get everything done on my shift’. In the survey
the least prevalent behaviours were those in which the team members
themselves monitored each other and were aware of function outside
of their work assignment.

The trust subscale on this questionnaire is focused on commu-
nication: team members trust each other enough to communicate
ideas and information and value, seek and give each other construc-
tive feedback, trusting that team members will receive feedback and
change as needed for the good of the team (Kalisch et al., 2010). What
is seen in a lower trust subscale is the lack of self- monitoring and
self- correcting through good communication found in highly effective
teams. Salas observed that feedback is essential for a team to function
effectively. This sort of feedback is not generally part of the typical
nursing unit culture as health care tends to function in a hierarchal
system of power and regulation. A levelled hierarchy tends to be a
prerequisite to teamwork and the lack of this dynamic is evident in the
low scores of the trust subscale.

Team orientation was the lowest scoring subscale. Team orienta-
tion describes a commitment to the goals and integrity of the team
versus personal objectives. It includes open discussion of behaviours
of team members, a supportive helpful attitude of collective responsi-
bility, feedback between members and conflict resolution. Teams with
high team orientation are more focused on the collective work than
their own responsibilities (Kalisch et al., 2010). Essentially low team
orientation scores indicate an individualist versus a collectivist mind-
set. This collectivist orientation of teams is the key feature of effective
teams as indicated by decades of team research (Salas et al., 2008).
Nurses represent the largest group of professionals who provide

patient care and have the most direct interactions with patients on
a daily basis. Thus nurses have an immense influence on patient out-
comes. Yet the unique structures and attributes of nursing teams are
relatively unexamined particularly in settings where the majority of
patient care is received. This study provides a large sample of nurs-
ing teams. This study affords a distinctive description of patient care
teams comprising specifically nurses. Understanding the team dy-
namics of nursing professionals and their support personnel offers a
unique opportunity to understand and impact those who provide the
most direct patient care.

The lack of correlation between teamwork and demographic fea-
tures such as gender and education shows that the factors of highly
effective teams are process- orientated and modifiable. The correla-
tions between teamwork and variables such as job satisfaction and
role satisfaction reinforce previous findings of the positive outcomes
of teamwork (Korner et al., 2015), and have implications for retention.

What is most important to this study is the description of the struc-
ture and dynamics of teamwork among nursing teams in acute care
settings. The disproportionately high leadership scores among acute
care nursing teams combined with lower subsequent subscales show
that nursing team characteristics differ from the known attributes of
highly effective teams. Salas’ Big Five Framework of Teamwork model
was developed by observing the characteristics of highly functioning
teams. For teamwork to be effective all the concepts and coordinating
mechanisms must be evident (Rochon, Heale, Hunt, & Parent, 2015).
The 74 units/areas examined in this study had a very broad range and
variety of skill mix, education, experience and satisfaction. Regardless
of these vast differences, every nursing unit showed a similar pattern
in the elements of teamwork with shared mental model and leadership
scoring highest, then a marked drop to backup and trust, followed by
team orientation as the least prevalent element.

The nursing teams in this study reflect members who have a clear
understanding of their responsibilities, work alongside each other re-
spectfully and are well coordinated by their nurse leader. The data
reflect a sense of ‘parallel work’ in that individuals do their own work
and collaborate, communicate and share information for specific sit-
uations. However, awareness and concern for other team members
presents an opportunity for improvement. Members of the nursing
team work alongside each other but are focused on their own pa-
tient assignments and responsibilities. There is little awareness of
other team members and backup behaviours to support others in
their work are not often practised. Overall teams in this survey did
not have a sense of higher purpose that transcends their personal
work domain.

While this study uniquely examines the teamwork of nurses there
are several limitations. No sampling techniques were used and the re-
sponse rate was below 40%, which is generally considered the mini-
mum rate to be representative. A proportion of respondents worked
in the team for less than 6 months and may not have a full under-
standing of the team dynamics. The results were based on responses
to a survey rather than observations of team behaviours and may be
influenced by the perceptions of the respondent. Finally, no outcomes
were measured in this study – it is simply a description of nursing

| 7KAISER And WESTERS

teams and does not explore the relationship between nursing team-
work and important clinical and patient outcomes.

6 | IMPLICATIONS FOR NURSE LEADERS

The benefits to be realized from effective teamwork are well docu-
mented and include improved client care and outcomes, professional
growth, greater job satisfaction and positive organisational outcomes.
Put broadly, synergy is the primary outcome of exceptional teamwork.
Synergy occurs when a team’s output exceeds what can be accom-
plished individually. Two critical attributes to a synergistic group in-
clude group cohesion and the pursuit of a common goal (Witges &
Scanlan, 2015).

The data from this study find that this goal orientation is lacking in
nursing teams. In nursing and health care it is agreed that patient well-
being, safety and ‘patient- centred care’ is a mutual, widely accepted
and valued goal among team members. While paramount this concept
is nebulous. General management strategies support the articulation
of SMART objectives and goal settings but this is rarely done in pa-
tient care. Yet anecdotal stories of excellence that focus on a particular
patient experience have shown that nursing teams can work syner-
gistically when there is a specific goal in mind. Nurse leaders are en-
couraged to set daily SMART objectives for the unit that can be clearly
realized and celebrated, to facilitate this sense of collective purpose.

A high level of group orientation is the key element lacking in the
nursing teams of this study. The question to nurse leaders becomes
how to achieve this level of collective orientation and cohesion. Only
intentional attention to teams and teambuilding can achieve this.
Studies have found that teamwork can be developed through individ-
ual and team competency training (Baker et al., 2006; Gaston et al.,
2016; Salas et al., 2008). TeamSTEPPS® Crew Resource Management,
simulation and other training methods have been widely deployed
in health care and have demonstrated positive results (Gaston et al.,
2016). Unit- based team building interventions related to work expec-
tations, communication, decision- making and conflict resolution have
been successful in creating effective nursing teams. Modifying tasks,
workflow or structure can also enhance teamwork (Baker et al., 2006).
Leaders can examine the conditions in which team- based work occurs
and re- design accordingly. Creating interdependencies creates the
conditions for teamwork to exist.

One specific way to create conditions that require interdependen-
cies is to redesign staffing structures. Researchers have suggested that
teams who are more familiar with each other may function better than
new teams (Rochon et al., 2015). Intuitively this makes sense and nurs-
ing leaders have responded by concerning themselves with retention
efforts to maintain employees. An even easier solution is to schedule
the same individuals together. The size of the hospital unit has been
found to impact teamwork, with smaller units having better teamwork
(Kalisch et al., 2013). Common staffing practices do not base sched-
ules on other employees resulting in an ever- changing group of in-
dividuals who comprise the nursing team. This practice may in fact
inhibit teamwork and should be considered.

A comprehensive model of team performance specific to nurs-
ing teams in acute and continuing care needs to be fully developed
to lay a scientific understanding of what compromises effective
teamwork in these settings. This study begins to contribute to this
work by describing nursing teams in relationship to Salas’ model of
teamwork which has been widely accepted as a prototype in both
health care and other high- reliability organisations. It is presumed
that the development of the components of this model will lead to
increased team performance. This assumption needs to be validated
with further research. Nurse leaders can use the information from
this study to focus on the areas for opportunity to build highly ef-
fective nursing teams.

ACKNOWLEDGEMENTS

Karen Vander Laan, PhD, MSN, RN and Sarah Geoghan, BSN, RN.

ORCID

Jennifer A. Kaiser http://orcid.org/0000-0002-7686-0213

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patient unit, and staff characteristics. Applied Nursing Research, 26, 2–9.
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8 | KAISER And WESTERS

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https://doi.org/10.1186/s12913-015-0888-y

http://PAREonline.net/getvn.asp?v=9&n=11

https://doi.org/10.1518/001872008X288457

https://doi.org/10.1111/jonm.12582

Improving
Hand-off
Report

Student Names

Team Name and First/Last Names of Participants

Problem
Report (timing and hand off errors): The unit manager of a medical surgical unit has observed that change of shift report takes greater than 45 minutes. In addition, staff has complained that their peers do not include vital data (IV sites, dressing sites, DVT prevention measures….) in report leading to errors, leave patients in disarray, and leave tasks incomplete. Our task is to propose a change that will address these issues.

Report (timing and hand off errors: Unit managers observed that there was miscommunication between staff during shift report. Often times leaving out important patient information as well as taking a significant amount of time to relay the information. Our goal it to offer a change that will address these issues.
Now here is our SWOT analysis starting off with Derrick talking about the strengths.

Majka
“Communication failures compromise patient treatment, care quality, and safety. It also leads to medical errors, the third leading cause of deaths in the United States” (Ghosh, et all., 2015)
“The varying parties and large amount of complex information included in patient handoff reports frequently contribute to informational gaps and omissions in the handoff report that can lead to sentinel events and patient hard” (Staggers & Blaz, 2013)
“Research has identifed handovers as a risky time in the care process, when information may be lost, distorted or misinterpreted (Borowitz et al 2008, Owen et al. 2009, Philibert 2009)

Report (timing and hand off errors): The unit manager of a medical surgical unit has observed that change of shift report takes greater than 45 minutes. In addition, staff has complained that their peers do not include vital data (IV sites, dressing sites, DVT prevention measures….) in report leading to errors, leave patients in disarray, and leave tasks incomplete. Your task is to propose a change that will address these issues.

Increase of errors during patient hand-off report leading to missed information and incomplete tasks
Hand-off report time is taking a greater deal of time
Our task is to implement the use of SBAR as the standard hand-off report between shifts in order to reduce errors and decrease the time spent giving report.
2

SWOT

Strengths:
Multidepartment focus addressing handoff report problems(Robins et al., 2017)
Solutions shorten time taken in report while increasing quantity of pertinent information. (Stewart & Hand, 2017)
SBAR is supported by the Joint Commision (Stewart & Hand, 2017)
Proven error reduction due to use of SBAR tool. (Stewart & Hand, 2017)
SBAR is an evidence-based hand-off tool (Eberhardt, 2014)

Weakness
Use of the tool requires education to reduce user error (Stacey Eberhardt 2014)
Medical personnel have personal bias on giving report (Ghosh et al., 2018)
Some staff are unreceptive to change (Robins & Dai, 2017).
Evaluating execution of report can be affected by observer bias (Robins & Dai, 2017)

Opportunities
SBAR is inexpensive as a tool and will earn its cost in education by the reduction of sentinel events (Stewart, 2017)
Improve patient handoff by implementing an evidence-based handoff tool in SBAR format (Eberhardt, 2014)
For continued nursing education in standardizing hand-off report (Ghosh et al., 2018).
Threats
Due to the variety of the change-of-shift reporting process, the findings of the study may not be applicable across similar settings (Ghosh et at., 2018).
Some staff are unreceptive to change (Robins et al., 2017).
Evaluating execution of report is subject to observer bias (Drach-Zahavy, 2014)
Small sample sizes from 2 studies: only one randomized control study (Stewart, 2017)

Strengths:
Multidepartment focus on addressing problems with handoff report (Robins et al., 2017)
Solutions manage to shorten time taken to give report while increasing the amount of pertinent information given in that time frame. (Stewart & Hand, 2017)
SBAR is supported by the Joint Commision (Stewart & Hand, 2017)
Error reduction due to use of SBAR tool. (Stewart & Hand, 2017)
SBAR is an evidence-based hand-off tool (Eberhardt, 2014)
Weakness (Wendy)
Use of the tool requires education for all staff to reduce user error (Stacey Eberhardt 2014)
Medical personnel have personal bias on how they want to give report (Ghosh et al., 2018)
Healthcare worker disinterest in changing how they give report. (Robins et al., 2017).
Subjective approach to measuring a handover’s strategies might be subject to bias, as participants may behave differently in the presence of an observer.
Opportunities (ashley)
SBAR is inexpensive as a tool and will earn its cost in education by providers by the reduction of sentinel events (each of which carries a high expense). (Stewart, 2017)
Improve patient handoff by implementing an evidence-based handoff tool in Situation Background Assessment Recommendation (SBAR) format (Eberhardt, 2014)
For continued nursing education in standardizing hand-off report (Ghosh et al., 2018).
Threats (Alma)
Due to the variety of the change-of-shift reporting process, the findings of the study may not be applicable across similar settings (Ghosh et at., 2018).
The acuity of patient injury and medical history can increase the amount of time for patient hand-off (Robins, 2017).
Small sample sizes from 2 studies: only one randomized control study (Stewart, 2017) and sample size of 200 handovers in 5 wards in another study(Drach-Zahavy, 2014)
3

Assessment
Inefficient communication during hand off report is a challenge to patient care. (Ghosh, et al., 2018)

Communication error given during report increases risk of poor patient outcomes. (Stewart, 2017)

Hand off communication between medical personnel leads to an increase in medication errors, incomplete tasks, disorder, and eventually poor patient outcomes (Robins et al., 2015)

According to The Joint Commission, communication errors have been among the top three leading root causes of reported sentinel events every year since 2004. (Stewart, 2017)

The information we had gathered from our assessment on giving report overall was –
1. Poor communication leads to poor patient outcome
2. The Joint Commission has stated communication errors has been the top 3 leading root causes of unanticipated major events in the healthcare setting that results in death or serious physical or psychological injury to a client which require immediate investigation by the health care facility since 2004
3. And now we will be talking about our Diagnosis.

Goal should comes from assessments (SMART (MEASURABLE))
Assessment will be bullet points of why is this a problem
Specific, measurable, attainable, realistic, timely

All RNs and assistive personnel will attend 1 or more in-services on the use of SBAR handoff report within three weeks.
During the same three week period, charge nurses and nursing management will include SBAR teaching in pre-shift meetings, encouraging staff to begin to practice using the SBAR template during report.
Following the three week introduction of SBAR to the staff, SBAR will be implemented on the unit for a trial period of 1 month with the goal of receiving ideas of how we can improve it from the staff at the end of the 1 month period.
At the end of the one month period, staff nurses and assistive personnel will be invited to discuss their experiences with SBAR, as well as any ideas they have to improve it, during pre-shift meetings, down-time during their shift, or via email with the nurse manager.
15 days into the trial month, as well as at the end of the trial month, the nurse manager will personally solicit input regarding SBAR from harvest nurses on the unit.
At the end of the 1 month trial period, metrics on sentinel events, falls, nosocomial infections, and other communication errors will be compared with the month prior to SBAR implementation and to the same month in the previous year.
During the second month, a new SBAR form that includes select suggestions from staff will be used by those staff members while other staff members continue to use the known SBAR report. Communication errors, sentinal events, falls, nosocomial infections, et al will be compared between the two systems.

Majka
4

Diagnosis
Lack of standardization in report
Communication Barriers (Stewart & Hand, 2017)
Communication practices learned by various career stages of nurses (promise, momentum, harvest)
Different individual communication styles
Gaps in knowledge regarding lack of standardized reporting

A lack of standardization in report increases risk of error and poor patient outcomes
5

S.M.A.R.T. Goal
Use an evidence-based standardized hand-off report tool to reduce report times to less than 45 minutes while reducing report-based errors by 20% within 6-month period.

Precontempemplation: Nurse manager goes to charge nurses, harvest nurses, and harvest support staff with the SBAR template and asks them to sit with it for one week. He or she will ask for feedback from these individuals about implementing it on the unit.
Contemplation: Harvest nurses and support staff, and charge nurses spend a week with the SBAR template and consider its strengths, weaknesses, and or simply form an opinion around it.
Preparation: nurse manager introduces in-services on SBAR and charge nurses begin introducing the template during pre-shift meetings.
Action: Nurses and support staff begin using the template during all hand-off reports for a one month period. Nurse manager seeks input from harvest staff on ways to improve the system and attempts to include their input on a trial period, thereby extending the practice of the original SBAR for another month with most staff, and offering a personalization to those interested in improving the system.
Maintenance: Nurse manager compares statistics from the same time period one year ago, to the same length of time prior to using the SBAR report, and the data from the SBAR report compared with the modified SBAR report and presents the data to the staff at a staff meeting. At the meeting the nurse manager encourages public input and opinions on the SBAR report. If there is resistance, the manager asks that SBAR be continued in practice for a 3 month period in which he or she will personally receive report from individuals on their patients – helping those nurses who need it with ways to be more succinct. At this point, the report will have been used in practice for 5 months and will have become habit for many of the staff.
Alma
6

Full-Range Leadership Model/Theory
Definition: Focuses on the behavior of leaders towards the workforce in different work situations. (Marquis & Huston, 2011)
Three sub-types
Transactional
Transactions between leaders and followers
Leaders promote compliance to standard SBAR method through rewards and punishments
Transformational
Identifies needed change, inspires, and executes change
Emphasize the importance of reducing errors in patient hand-off through application of SBAR. Our goal is to enhance quality of care and thorough communication.
Laissez-faire
No standard rules
Used when nursing staff and PCTs are efficient with and advocating use of SBAR

Full Range Leadership: Promise, Momentum, Harvest
Wendy

Transactional: Promoting buy-in from nurses and PCTs through encouragement of ideas and discussion while also increasing of stakeholder support of the SBAR method

Theory should apply to what we are trying to accomplish
“this is how we plan to use this leadership style because….”
Why is this theory important for our outcome?
Using more then one theory, where is it applicable?

Plan

Following the three-week introduction of SBAR to the staff, SBAR will be implemented on the unit for a trial period of one-month with the goal of receiving ideas of how we can improve it from the staff at the end of the one-month period.
At the end of the one-month period, staff nurses and assistive personnel will be invited to discuss their experiences with SBAR, as well as any ideas to improve it, during pre-shift meetings, down-time during their shift, or via email with the nurse manager.
15 days into the trial month, as well as at the end of the trial month, the nurse manager will personally solicit input regarding SBAR from harvest nurses on the unit.
At the end of the one-month trial period, metrics on sentinel events, falls, nosocomial infections, and other communication errors will be compared with the month prior to SBAR implementation and to the same month in the previous year.
During the second month, a new SBAR form that includes select suggestions from staff will be used by those staff members while other staff members continue to use the known SBAR report. Communication errors, sentinel events, falls, nosocomial infections, et al will be compared between the two SBAR report templates at the end of a one-month trial.
8

3 Weeks

RNs and assistive personnel to attend 1 or more in-services on SBAR handoff report

Following in-service, SBAR teaching in pre-shift meetings, encouraging staff to begin to practice using the SBAR template during report.

1-month trial

SBAR will be implemented on the unit for a trial period with the goal of receiving ideas of how we can improve it from the staff at the end of the one-month period.

15 days into the trial month/ after the trial month

Nurse manager will personally solicit input regarding SBAR from harvest nurses on the unit.

Post 1-month trail

Staff invited to discuss their experiences with SBAR, to share ideas to improve it

Second trial(1 – 3 months)

New SBAR form that includes select suggestions from staff will be used. Communication errors, sentinel events, falls, nosocomial infections, et al will be compared between the two SBAR report templates at the end of a one-month trial. Then again at the end of three months.

Metrics on sentinel events, falls, nosocomial infections, and other communication errors will be compared with the month prior to SBAR implementation and to the same month in the previous year.

Implementation Through: The Transtheoretical Model: Stages of Change
Precontemplation
Discuss report issues with charge nurses and harvest nurses, asking them for ideas.
Contemplation
Charge and harvest nurses sit with knowledge of the problem. Offer them research on SBAR.
Present plan to stake holders. Invite CNO, directors, harvest nurses and PCTs.
Preparation
Supply staff with SBAR templates, offer in-services on SBAR communication education, and educate on SBAR during pre-shift meetings.
Action
Implement SBAR template during hand-off report.
Maintenance
Continue buy-in from harvest nurses and other staff by asking them to help personalize the form for the unit
Set performance goals related to hand-off associated errors.
Highlight problems related to hand-off report during pre-shift report and how SBAR could circumvent those.

PDF- page 96 management theory
PDF- page 107 leadership theory

Evaluation

Desired Outcome
Actual Outcome
Maintain Goals and Desired Outcomes

Lower amount of time giving report by < 45 minutes Implement standardized SBAR throughout the unit, structuring the process Nurses will be able to demonstrate standardized process of hand-off report Statistical significance in decreasing the rate of communication errors that leads to errors in patient care Amount of time giving report has decreased by using a standardized process (Stewart & Hand, 2017) Standardized process of giving report increased efficiency of verbal communication (Stewart & Hand, 2017) Decrease in the rate of callbacks for information clarification (Robins & Dai, 2017) Use of the SBAR tool during handoffs in a quasi-experimental study decreased the proportion of incident reports related to misunderstanding, misinterpretation, or omission of information from 31% to 11% (Stewart & Hand, 2017 Provide continuous education throughout clinical experience on usage of the standardized process of giving report (Stewart & Hand, 2017) Standardized process for reporting reduces hierarchical barriers (various career stages) increases confidence of the users, decreases length of report time and accuracy of exchanged information. (Stewart & Hand, 2017) - Use of the SBAR tool during handoffs in a quasi-experimental study decreased the proportion of incident reports related to misunderstanding, misinterpretation, or omission of information from 31% to 11% (Stewart & Hand, 2017) -Discuss if this is successful and why? The reasons Nurses are encouraged to seek new ways to implement best practices as they work (Eberhardt, 2014) 10 Implementation Barriers Medical personnel have personal bias on giving report (Ghosh et al., 2018) Different nurses have different approaches to how they perform report (Ghosh et al., 2018) Some staff are unreceptive to change (Robins & Dai, 2017) and it is difficult to [enforce a] change in practice for long time staff (Eberhardt, 2014) Majka - Our 3 main hurdles that prevent implementation is different nurses give report in different ways and personnel being biased with giving report, as well as, some staff don't want to change their styles of giving report such as more seasoned nurses that have been in the profession for many years. With that being said here are some questions to think about... 11 Questions to Think About Why is SBAR preferred to personalized hand off reporting? What limitations do you think SBAR represents when giving report? Is it more beneficial to use a single standard SBAR tool or to personalize the tool to match specific units? Why? References Drach-Zahavy A ; Hadid N. Nursing handovers as resilient points of care: linking handover strategies to treatment errors in the patient care in the following shift. J Adv Nurs. 2015; 71: 1135-1145 Ghosh, K., Curl, E., Goodwin, M., Morrell, P., & Guidroz, P. (2018). An Exploratory Study on how to Improve Bedside Change-of-Shift Process: Evidence from One Hospital Using Technology to Support Verbal Reporting. HICSS. Marquis, B.L., & Huston, C. (2011). Leadership roles and management functions in nursing: Theory and application (9th ed). Lippincott, Williams, Wilkins. ISBN: 978-1-4963-4979-8 Robins, H., & Dai, F. (2015). Handoffs in the Postoperative Anesthesia Care Unit: Use of a Checklist for Transfer of Care. AANA journal, 83 4, 264-8. Stewart, Kathryn R., "SBAR, communication, and patient safety: an integrated literature review" (2016). Honors Theses. https://scholar.utc.edu/honors-theses/66 image1 image2 image3 image4 image5 image6 image7 image8 image9 image10 image11

Student Name:

EBP Journal Article in APA format:

Walker, F. A., Ball, M., Cleary, S., & Pisani, H. (2021). Transparent teamwork: The practice of supervision and delegation within the multi‐tiered nursing team.
Nursing Inquiry,
28(4), 1-10. https://doi.org.resu.idm.oclc.org/10.1111/nin.12413

.2 points

.4 points

Is this an Evidence Based Article? Name of Journal and Year article was written?	Yes/No Name of Journal: Nursing Inquiry Year: 2021		.2 points
State the problem What was the goal of the project in the article? Does this project correlate with your problem? State how? What are you trying to achieve? Does this article support this goal?	Problem: The problem is how supervision and delegation of a NA position are practiced in a multi-tier nursing team. Goal: To promote the development of transparent nursing practices and mutual understanding in the multi-tier nursing team to facilitate effective supervision and delegation based on informed decision-making and a culture of openness and trust. State how this article correlates with your group problem and goal. The article correlates with the problem and goal because it discusses how to enhance teamwork across care provider levels. It outlines how transparent nursing practices can lead to effective supervision and delegation, leading to high-quality patient care. The article shows how effective communication between RNs and NAs, can lead to teamwork, which is what our group project is aiming for. Our goal is to propose a plan to enhance teamwork between the RNs and PCTs on a med/surg unit and that correlates with the article.
Strengths (Internal) What’s was good about your article?	Why was this project successful? Participants: It was successful because it included NA, nurses and nursing leaders who were policymakers, managers, supervisors, and educators whom all supported the study. Participants had to have direct involvement in the development or implementation of the NA model, worked directly with a NA, or worked in the role of a NA and they were to reflect the stakeholder population. The participants were familiar with the organization’s objectives and policies due to 1+ years of employment. Research Methods: Data was collected through individual interviews, focus groups, and documentary evidence. Interview and focus groups were audio-recorded and transcribed verbatim and for the interviews, participants had to verify their transcripts sent to them. To verify conclusions from the data analysis, triangulation of multiple sources was used. The researcher made sure to utilize documents that were from a variety of sources, audiences, and purposes. The various methods contributed to preventing any bias. Efficiency: The results of the study proved that a clear understanding of roles, transparency from the RNs when delegating and supervising NAs, along with trusting and open communication empowered teamwork. This would enable both parties to provide quality patient care and patient satisfaction. List attributes of the article, i.e. support from administration, councils, colleagues, institutions. Attributes of this article included honest opinions gathered from senior managers, nurse educators, clinical nurse specialists, RNs, ENs, and policymakers during their individual interviews. Did this implementation take place on a unit or area like yours? It took place at a tertiary hospital and an acute setting that included 13 medical, surgical, and specialty wards.	.4 points
Weakness (Internal)- issues	Participants: Based on the researcher the interpretation of the NAs’ role and boundaries by RNs were the most pertinent issues. There was no transparency in communication when RNs delegated and supervised. RNs had an issue with having to take accountability for the NA when delegating to them, which resulted in a communication breakdown. Styles of the delegation were also something else that hindered teamwork leading to negative outcomes and the NAs not being receptive to what was asked of them. Some nurses also disagreed with them needing additional education. Sample: The sample of RNs, nursing leaders and NAs were all members of the same hospital, so this would not provide evidence for the RN and NA’s teamwork in a nursing care facility.			.4 points
Opportunities (External)	Participants: There is a need for improving supervision, delegation, roles, and responsibilities through education. The research showed that successful delegation depended on effective communication, teamwork, positive interpersonal relationship, and sharing of knowledge. Since there seemed to not be enough education about each other roles, this would be a good opportunity to include that. Baseline data: This study showed that mutual understanding, ward culture, workload, mutual understanding, knowledge, skills, and competence influenced delegation and supervision like previous research on this topic. research supports that multi factors affect the practices of nursing supervision and delegation within a multi-tiered nursing team.
Threats – (External)	Barriers: Researchers found that some nurses had issues with accountability. The interpretations and how it was practiced differed based on the units’ environment. Improving delegation and supervision through additional education was rejected by some nurses who felt their delegation was at a satisfactory level already. They also found that some new grads lacked confidence in delegation and supervision of NAs because they felt like they had not received the proper training on it. Ultimately if the RNs and NAs can’t exhibit cohesive teamwork it reflects in the unit, and patient care leading to complaints from them and the patients. Sample: The article argues that education on the roles, communication, and transparency are major key factors for effective teamwork, but it does not address if it could provide the same results in a more efficiently run hospital. Participants also were from acute settings and none were from outpatient, or hospice.

Total Points = 2 points

Student Name:

EBP Journal Article in APA format:

Kaiser, J. A., & Westers, J. B. (2018). Nursing teamwork in a health system: A multisite study. Journal of Nursing Management, 26(5), 555–562. https://doi.org/10.1111/jonm.12582

.2 points

.4 points

Is this an Evidence-Based Article? Name of Journal and Year article was written?	Yes Name of Journal: Journal of Nursing Management Year: 2018		.2 points
State the problem What was the goal of the project in the article? Does this project correlate with your problem? State how? What are you trying to achieve? Does this article support this goal?	Problem: A manager of a medical-surgical unit has seen and had a lot of complaints concerning the lack of teamwork between the registered nurses and the patient care techs; hence necessary measures need to be taken in order to promote teamwork in that unit. Goal: The goal of the project was to investigate the way different features of teamwork exist among nurse-only teams in acute and continuing health care settings. This article correlates with our group problem, which is the lack of teamwork between registered nurses and the patient care techs since it outlines the key elements required in order to promote effective teamwork in a health care setting. This article provides great insights on how teamwork can be enhanced in healthcare by focusing on the” Salas’ Big Five” model of teamwork. This model is centered on various teamwork behaviors and provides a practical explanation of the dynamics of teamwork. According to the framework, necessary knowledge, skills and attitudes are needed to promote teamwork. Salas holds that highly effective teams must regularly demonstrate certain knowledge, skills and attitudes, which can also help in dealing with the issue in the medical surgical unit. Based on the article, teamwork between the registered nurses and the patient care techs can be enhanced by having a clear and common purpose, compensating for each other and consistently providing feedback to each other. Other ways of promoting teamwork among the two parties include reallocation of functions, valuing team goals rather than individual goals, anticipating one another’s actions and needs and strongly believing in the team’s collective capability to succeed.
Strengths (Internal) What’s was good about your article?	The nursing teamwork survey, which was utilized in measuring teamwork in the nursing work environment, demonstrated reliability, validity and acceptability. The score of team leadership in the study was relatively high. Members of the team were well coordinated by their nurse leader in that the health care providers did their work and collaborated besides communicating and sharing information for certain situations. Yes. This project was implemented in acute care settings.	.4 points
Weakness (Internal)- issues	Despite the study uniquely evaluating the teamwork of nurses, there are some weaknesses. For instance, the response rate was below forty per cent, and some of the participants worked in the team for less than six months, making it hard to understand the team’s dynamics fully. The obtained results were centered on responses to a survey that was carried out instead of observations of team behaviors which might have influenced the respondent’s perceptions in different ways. Moreover, no results were measured in this research because it is just a description of the nursing team and does not look at the connection between nursing teamwork and important clinical and patient outcomes.			.4 points
Opportunities (External)	Based on the results of the study, it was discovered that team members are usually clear on the responsibilities and tasks expected of themselves and other individuals. Results show that the team members felt that they worked well together and always respected and valued one another as team members. Additionally, team members recognized each other’s strengths and weaknesses because they worked together more often.
Threats – (External)	Based on the study, there was no satisfaction and efficacy of the physicians in providing the necessary leadership skills which can help in promoting true teamwork. Another key aspects that serve as threats are low team orientation and low trust. According to the researchers, team orientation was low, which implies that there was no commitment by the team members to the goals and integrity of the team versus personal objectives. Lower trust between team members can result in certain issues, such as lack of monitoring and self-correcting through appropriate communication seen in highly effective teams. Even though the teams valued each other, there was a predominant mindset of clear role delineation and work assignments among the team members.

Total Points = 2 points

Student Name:

EBP Journal Article in APA format:

Ballangrud, R., Aase, K., & Vifladt, A. (2020). Longitudinal team training programme in a Norwegian surgical ward: a qualitative study of nurses’ and physicians’ experiences with teamwork skills.
BMJ open,
10(7), e035432.

.2 points

.4 points

Is this an Evidence Based Article? Name of Journal and Year article was written?	Yes Name of Journal: A qualitative study of nurses’ and physicians’ experiences with teamwork skills Year: 2019		.2 points
State the problem What was the goal of the project in the article? Does this project correlate with your problem? State how? What are you trying to achieve? Does this article support this goal?	Problem: There is uncertainty in determining the impact of teamwork and interprofessional team training in enhancing continuity in provision of high-quality care in a complex medical setting such as surgical procedures and ward. Goal: The study aims at describing healthcare professionals’ experiences with teamwork during surgical process following an implementation of longitudinal interprofessional team training programmer. State how this article correlates with your group problem and goal. The article focuses on the impact of teamwork in complex clinical settings or backgrounds. This aligns with the group problem which is enhancing teamwork between the registered nurses and patient care techs. In both cases, there is analysis of teamwork and the impact it has in ensuring there is provision of high-quality care in complex medical units such as surgical units.
Strengths (Internal) What’s was good about your article?	Why was this project successful? The project was very successful in the approach used in collecting data from the participants of the study. There were three distinct stages to the analysis process: planning, execution, and reporting. The first two stages were conducted by RB and AV with help from KA, and the third stage was conducted by all three authors. During the pre-analysis phase, we treated each interview as a discrete unit of analysis and examined information from Time Points Zero, One, and Two independently. Each interview was read by all three authors multiple times to ensure familiarity with the data, and using the objectives and questions, the researchers learned extensive details about the participants’ experiences with teamwork. Effective planning of the project: In the planning stage, the authors set up a structured analysis matrix with columns for the many aspects of organization, including communication, leadership, situation monitoring, and mutual assistance.	.4 points
Weakness (Internal)- issues	Limited scope of study: The project focused at healthcare providers within the surgical unit during the first encounter. Even after recognizing the potential changes after receiving feedback, there was no study conducted to determine the impact of feedback received following the study. Bias: The small study size and potential bias in the sample due to participants’ preconceived notions of teamwork on the surgical ward could also skew the results. The findings cannot be generalized, but thanks to the qualitative nature of the study, there is a better grasp on how health workers’ experiences with newly acquired collaboration abilities have played out in practice, which may have implications for other hospital wards. The results may have been impacted by the fact that the interview times were frequently changed by the healthcare providers due to time constraints and busyness on the surgical ward. After 6 months, two sets of attending physician took part in the interviews, but after 12 months, just one physician took part.			.4 points
Opportunities (External)	There is a need to conduct further study in determining the impact of feedback among team members. This is evident as the study identifies changes in performance of healthcare providers following reception of feedback. There was a heightened awareness of feedback among both RNs and CNAs. When unfavorable occurrences occurred, they found the tools helpful, and they received lots of encouragement from the entire interdisciplinary team. Nurses saw a decline in the ‘go to the leader’ approach when employees were dissatisfied, and they heard less complaints from coworkers who wanted to voice their concerns. The nurses had also witnessed newer nurses who were willing to advocate for their patients. But they also believed that healthcare professionals were cagey at times, suggesting there was always space for development in the two-way exchange of opinions. Expansion of scope: There is a need to explore more options in choosing appropriate participants for the study before coming up with the final solutions and recommendations in relation to the use of teamwork in enhancing success and realization of outcomes.
Threats – (External)	Threat of confirmation bias: With the narrow scope of study and participants relied on the study, there is higher chances of inappropriate conclusion made from the findings. Validity: The study project involved limited number of participants which in turn presents a potential cause of inconsistency if a different set of participants were used in the study. Because majority of the nursing staff attended the refresher courses, the outcomes may have been different if a wider number of physicians had participated. Patient safety efforts, such as the Medical Emergency Warning System (MEWS) and patient safety whiteboard meetings, recently implemented in the ward in anticipation of the team training programme may also have influenced the results.

Total Points = 2 points

ENHANCING TEAMWORK

Tiffini Collier

Kal Haile

Omolola Adebisi

2
Problem
Report: Enhancing teamwork across care provider levels: The manager of a medical-surgical unit has observed and had complaints about, lack of teamwork between the RN’s and the patient care techs (PCT’s). Our task is to propose a plan to enhance teamwork on the unit

ADD A FOOTER
3

Strengths:
The survey developed to assess collaboration in the nursing profession was shown to be reliable, valid, and acceptable in practice. (Kaiser, et al., 2018)
The nurse in charge of the team did an excellent job of coordinating the efforts of the other members, ensuring that everyone did their part and worked together as a unit . (Kaiser, et al., 2018)
Through repeated readings of each interview, all three writers were well acquainted with the data gleaned from the participants’ responses to the goals and questions, which provided rich information about the participants’ experiences with collaboration. (Ballangrud, 2020)
The research found that defined responsibilities, transparency from RNs while delegating and overseeing NAs, and trusting and open communication boosted collaboration.(Walker, 2021)

Weakness
There was no transparency in communication when RNs delegated and supervised. (Walker, 2021
the response rate was below forty per cent, and some of the participants worked in the team for less than six months, making it hard to understand the team’s dynamics fully. (Kaiser, et al., 2018)
Even after recognizing the potential changes after receiving feedback, there was no study conducted to determine the impact of feedback received following the study. (Ballangrud, 2020).

Opportunities
Even after recognizing the potential changes after receiving feedback, there was no study conducted to determine the impact of feedback received following the study.(Ballangrud, 2020)
Results show that the team members felt that they worked well together and always respected and valued one another as team members. (Kaiser, et al., 2018)
The research showed that successful delegation depended on effective communication, teamwork, positive interpersonal relationship, and sharing of knowledge. (Walker, 2021).
Threats
Based on the study, there was no satisfaction and efficacy of the physicians in providing the necessary leadership skills which can help in promoting true teamwork(Kaiser, et al., 2018)
With the narrow scope of study and participants relied on the study, there is higher chances of inappropriate conclusion made from the findings(Ballangrud, 2020).
Research found that some nurses had issues with accountability. The interpretations and how it was practiced
differed based on the units’ environment. (Walker, 2021)

Reference

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10/1/22, 10:21 AM Week 3: Assignment 4 (EBP “PowerPoint Slide 3 – SWOT Analysis”) – NUR4640-03:Leadership & Management in Nursing (2022 Fall Term 1)-15269 – Resurrection University

https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=42617&grpid=19198&isprv=0&bp=0&ou=18645 1/4

Group EBP Weekly Group Powerpoints
Course: NUR4640-03:Leadership & Management in Nursing (2022 Fall Term 1)-15269

Criteria Exemplary Average Needs Improvement Inadequate Criterion Score

Content

Knowledge / Flow

/ 0.5

0.5 points

-Follows all

requirements for

the assignment.

-Conveys well-

rounded knowledge

of the

topic.

-Well-organized.

-Information flows

in logical and

interesting

sequence.

0 points

-Follows some

requirements for

the assignment.

-Conveys some

knowledge of the

topic.

-Organization needs

improvement.

-Information does

not flow in logical

and interesting

sequence.

0 points

Does not meet any

of the requirements

10/1/22, 10:21 AM Week 3: Assignment 4 (EBP “PowerPoint Slide 3 – SWOT Analysis”) – NUR4640-03:Leadership & Management in Nursing (2022 Fall Term 1)-15269 – Resurrection University

https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=42617&grpid=19198&isprv=0&bp=0&ou=18645 2/4

Criteria Exemplary Average Needs Improvement Inadequate Criterion Score

Clarity, Critical

Thinking

/ 0.5

Writing

Composition

(Spelling,

Grammar,

Sentence

Structure)

/ 0.5

0.5 points

– Consistently

analyzes

information, offers

insight, and draws

conclusions.

-Scholarly work.

0 points 0 points 0 points

– Does not

consistently analyze

information, offers

insight, and draws

conclusions.

0.5 points

– Writing, grammar,

spelling, transitions,

readability, and

sentence structure

are error

free.

0.3 points

-An occasional error

may occur, but

writing, grammar,

spelling, transitions,

readability, and

sentence structure

are essentially error

free.

0.2 points

-3 to 5 errors in

writing, grammar,

spelling, transitions,

readability, and

sentence structure.

0 points

More than 5 errors

in writing, grammar,

spelling, transitions,

readability, and

sentence structure.

10/1/22, 10:21 AM Week 3: Assignment 4 (EBP “PowerPoint Slide 3 – SWOT Analysis”) – NUR4640-03:Leadership & Management in Nursing (2022 Fall Term 1)-15269 – Resurrection University

https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=42617&grpid=19198&isprv=0&bp=0&ou=18645 3/4

Total / 2

Criteria Exemplary Average Needs Improvement Inadequate Criterion Score

References/ APA

Format

/ 0.50.5 points

-Information

gathered from a

variety of nursing

journals and nursing

and/or medical

organization

websites.

– Articles are within

5 current references

within the last 5

years.

-The PowerPoint

are error-free,

following APA

format in the body

of the PowerPoint

and reference page.

0 points 0 points 0 points

10/1/22, 10:21 AM Week 3: Assignment 4 (EBP “PowerPoint Slide 3 – SWOT Analysis”) – NUR4640-03:Leadership & Management in Nursing (2022 Fall Term 1)-15269 – Resurrection University

https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=42617&grpid=19198&isprv=0&bp=0&ou=18645 4/4

Overall Score

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9 points minimum

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14 points minimum

Level 2

9 points minimum

Level 1

0 points minimum

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